Coronavirus (COVID-19) Screening

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
Should be Empty: