Visitor Health Screening
Guthrie Mainstream Services
Sign in to Google to save your progress. Learn more
Name of Visitor *
Contact Number *
Whom are you visiting? *
Purpose of visit? *
1. Are you currently experiencing, or have you experienced in the past 14 days, any of the following symptoms? (check all that apply) *
2. In the past 14 days, have you been in close proximity to anyone with the above symptoms or who has tested positive for COVID-19? *
3. Have you received the COVID-19 Vaccination?
Clear selection
I understand I need to inform Guthrie Mainstream Services if I test positive for COVID-19, within 3 days of visiting a GMS facility. *
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy