Coronavirus Screening Form
Full Name
*
First Name
Last Name
Phone Number
*
Format: (000) 000-0000.
Chart Number
*
Do you have any of the following symptoms?:
*
New and persistent cough
Shortness of breath or any difficulty breathing
Fever
No Symptoms
Have you been in contact with anyone in the last 14 days who is experiencing these symptoms?
*
Yes
No
Have you been in contact with anyone who has since tested positive for Covid-19?
*
Yes
No
Not Sure
Have you travelled abroad in the last 1-2 months? Where did you go?
Reason for Appointment:
*
Advice:
*
Email lab results, phone encounter appointment, come into the office.etc
Customer Service Representative filling out this form:
*
Submit
Should be Empty: