Healthcare Facility Access Check-in
Please complete this form to check in for your visit. Your information helps us maintain a safe and healthy environment.
Full Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Date and Time of Entry
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Purpose of Visit
*
Patient Appointment
Visitor
Staff Entry
Delivery
Other
Person or Department You Are Visiting
Have you experienced any of the following symptoms in the past 14 days?
*
Fever or chills
Cough
Shortness of breath
Loss of taste or smell
None of the above
Have you had close contact with anyone diagnosed with a contagious illness in the past 14 days?
*
Yes
No
Recent Travel History (last 14 days)
Current Body Temperature (°F or °C)
Emergency Contact Name and Phone
Signature
*
Check In
Check In
Should be Empty: