COVID19 Screening

Name *

Phone Number *

Do you currently have any of the following respiratory symptoms? *

Cough

Shortness of breath

none

Required

Do you currently have any of the following symptoms? *

Fever

Sore Throat

Chills

Loss of taste or smell

None

Required

Have you traveled within the last 2 weeks? *

Yes

No

Have you knowingly been exposed to COVID19 in the last 2 weeks? *

Yes

No

I understand that I will be asked to use hand hygiene and wear a mask during my appointment. *

Yes