Pre-Screening Form

Name

First NameLast Name

Date of Birth

Email

example@example.com

Please check YES or NO next to each question.

1. In the last 14 days, have you or anyone you have had close contact with experienced any of the following symptoms?

a. Fever, chills, or shaking

b. Difficulty breathing (not severe)

c. New or worsening cough

d. Sore throat

e. Headache

f. Muscle pain and/or aching throughout the body

g. Vomiting or diarrhea

h. New loss of taste and/or smell

2. In the last 14 days, have you traveled internationally?

3. In the last 14 days, have you or anyone you have had close contact with been diagnosed with COVID-19?

ATTESTATION:

My signature below certifies that the answers to the above statements are true and correct.

My signature below also indicates that I am aware that my charges for today's visit will be charged to my credit card on file. Due to contactless check out procedures, I understand that I will not be asked to sign a receipt but a copy of my receipt will be emailed to me

Signature

Date Signed

Date