Coronavirus (COVID-19) Screening
Dermatology Center of McKinney, 5801 Virginia Parkway, Suite 102, McKinney, TX 75071
Patient Name
*
First Name
Last Name
Date of Birth
*
In the last 30 days, have you traveled internationally?
*
Yes
No
Do you have any symptoms of a respiratory infection (e.g., cough, sore throat, fever or shortness of breath), diarrhea, or loss of taste or smell?
*
Yes
No
Have you had any recent contact with patients either diagnosed with or exposed to Coronavirus (COVID-19)?
*
Yes
No
In the last 14 days, have you traveled outside of the State of Texas?
Yes
No
Where outside of Texas have you traveled in the last 14 days?
Patient (Parent/Guardian signature if patient is under 18) or Vendor
*
Patient/Guardian Signature
Clear
Printed Name
*
First Name
Last Name
Relationship to Patient
Date
-
Month
-
Day
Year
Date
Submit
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