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PATIENT - COVID-19 SCREENING FORM
Please fill out and submit this form to complete prescreening.
  • 1
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    Pick a Date
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  • 2
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  • 3
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  • 6
    Not related to a known existing condition.
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  • 7
    Not related to a known existing condition.
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  • 8
    On a PCR test or rapid test.
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  • 9
    Answer NO if you have had a booster, are a double vaccinated youth 11-17 or have tested positive in the past 90 days.
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  • 10
    Due to contact tracing or close contact.
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  • 11
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