COVID19 screening form
Please complete no more than 48 hours of your appointment time.
Today's Date
-
Month
-
Day
Year
Date
Appointment Date
-
Month
-
Day
Year
Date
Patient's Name
*
First Name
Last Name
Patient's date of birth
*
-
Month
-
Day
Year
Date
Do you have any of the following NEW symptoms in the past 48 hours? Fever or chills, new or persistent cough, shortness of breath or difficulty breathing, headache, loss of smell or taste
*
Yes
No
Within the past 14 days have you been in close contact (6 feet more than 15 minutes with anyone who is having symptoms of COVID OR has tested positive for COVID?
*
Yes
No
Have you tested positive for COVID within the past 14 days OR have you taken a test and are waiting for the results?
*
Yes
No
Submit
Should be Empty:
Now create your own JotForm - It's free!
Create your own JotForm