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COVID-19 Symptom Check
For anyone who will be entering Hamilton-Garrett, please fill out this form prior to your arrival. While at Hamilton-Garret we are doing our best to ensure the safety of everyone is a priority, we appreciate your collaboration.
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Name
*
Your answer
Today's Date
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MM
/
DD
/
YYYY
Phone Number
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Your answer
Which program at HGMA are you attending today?
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Your answer
Do you have TWO (2) or more of the following symptoms?
Please review COVID-19 Symptoms:
Do I have (2) or more of the above symptoms?
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Yes I have
No, I do not have
Do you have any ONE (1) of the following symptoms?
Please review COVID-19 Symptoms:
Do I have any of the above symptoms?
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Yes I have
No, I do not have
Have you been diagnosed with COVID-19 over the previous 10 days?
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Yes
No
Have you been in close contact with (within 6 feet for 15 or more minutes) someone, in the past 48 hours, who has been diagnosed with COVID-19?
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Yes
No
Are you currently in self-isolation or quarantine at the direction of a medical professional or a public health official?
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Yes
No
Please confirm that you have only provided accurate information in this form.
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Yes, I have
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