First Point of Contact Screening

 

Date of Birth

We are committed to providing a safe environment for our patients and staff. If you answer “YES” to any of the questions, please help us prevent the spread of germs by putting on a mask and performing hand hygiene.

1. Do you have any of the following symptoms?
    Fever
     Yes
     No

    Cough
     Yes
     No

    Difficulty breathing/shortness of breath
     Yes
     No

    Sneezing or runny nose
     Yes
     No

    Body Aches (other than from injury
     Yes
     No

    Night sweats
     Yes
     No

    Severe Headaches
     Yes
     No

    Stiff Neck
     Yes
     No

    New rashes or open sores with fever
     Yes
     No

    Eye redness, swelling or discharge
     Yes
     No

    Unexplained bleeding
     Yes
     No

    Vomiting or diarrhea
     Yes
     No

2. In the past 3 weeks have you traveled either within the US or internationally?
     Yes
     No

3. In the past 3 weeks have you had close contact with someone who has traveled either within the US or internationally?
     Yes
     No

4. Have you been in close contact with a person confirmed to have COVID-19?
     Yes
     No

    Have you been tested for COVID-19?
     Yes
     No

    Have you been vaccinated?
     Yes
     No

Signature – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.

 

Date