Date
*
-
Year
-
Month
Day
Date
What is your First and Last Name?
*
First Name
Last Name
Have you had a COVID Test?
*
Yes
No
If 'YES', who gave you approval?
Vicki Duvall
Zee Chambliss
Kelly Simon
Tammy Wilson
Monica Kerns
Other
What Type of Visitor are you?
*
Member: Family/Friend
Vendor/Delivery
Member Private Duty Caregiver
Employee
Cypress Member
Leaving or Returning.
Leaving
Returning
Returning from Where
Emergency Room
Hospital
Over 24 Hours Away
Other
Doctors Office
If 'other' where are you returning from.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Where are you going?
Email
example@example.com
Phone Number
*
Name of Member you are visiting?
First Name
Last Name
Name of your Company?
Company Phone Number
Are you currently exhibiting any of the follow
Cough
Shortness of Breath
Chills or body aches
Diarrhea
Vomiting
New Loss of Taste
New Loss of Smell
Difficulty Breathing
Repeated shaking with chills
Muscle Pain
Headache
Sore Throat
N/A
Where did you Travel?
If 'NO' then send them away and give them contact info for Kelly Simon or Zee Chambliss.
Signature of Screener.
Submit
Should be Empty: