Infectious Disease Screening
This must be completed the same day as your appointment.
Date
*
-
Month
-
Day
Year
Date
Child's Name
*
First Name
Last Name
Child's Name
First Name
Last Name
Child's Name
First Name
Last Name
Child's Name
First Name
Last Name
Parent / Guardian
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Do you or the child(ren) attending have any of the following symptoms?
*
New and persistent cough
Shortness of breath or any difficulty breathing
Fever
Vomiting
Diarrhea
No Symptoms
Have you or your child(ren) been in close contact with anyone in the last 10 days who is experiencing these symptoms?
*
Yes
No
Have you or your child(ren) been in close contact with anyone who has since tested positive for Covid-19 in the past 10 days?
*
Yes
No
Not Sure
Submit
Should be Empty: