COVID-19 Screening Form

Weekly COVID-19 Screener
As providers of essential medical treatments, we aim to provide a safe environment. To ensure the safety of both our patients and staff, it is critical that the information submitted in this form is as accurate as possible.
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Have you experienced any of the following symptoms in the past 7 days? *
 
In the past 7 days have you had close contact with anyone who has been diagnosed with COVID-19 or suspected to have COVID-19? *
In the past 7 days have you visited any other cities/states/countries? *
(For example: I went to San Antonio - Friday, Saturday, and Sunday)
In the past 7 days have you had any visitors (Family, friends, etc) from out of town?
(For example: Family members from Denver stayed the weekend)
In the past 7 days have you been to any gatherings or events which more than 5 people were in attendance? *
(For example: I went to a concert where I was seated 6 feet away from people)
In the past 7 days have you visited any of the following places: