Within 24 hours of appt Covid-19 Screener

Full Name *

Phone *

Email *

Please add additional family members names here only if they have appointments and/or if they are a minor.

Have you experienced any of the following symptoms in the last 24 hours prior to your appointment?

Appointment(s) Day: *

Today
Tomorrow

Fever or Chills *

Yes
No

Cough *

Yes
No

Shortness of breath or difficulty breathing *

Yes
No

Muscle or body aches *

Yes
No

Headache *

Yes
No

New loss of taste or smell *

Yes
No

Sore throat *

Yes
No

Congestion or runny nose *

Yes
No

Nausea or vomiting *

Yes
No

Diarrhea *

Yes
No

Have you been exposed or advised to self-quarantine because of exposure to someone with COVID-19 in the last 14 days? *

Yes
No

Have you been advised to self-quarantine due to traveling in the last 14 days? *

Yes
No

If you answered yes to any of the health screening questions, click SUBMIT + reschedule your appointment for at least 72 hours after being symptom free, without having taken fever-reducing medicine OR 14 days after exposure to a suspected or confirmed COVID-19 positive individual.

If you answered no to the above screening questions, click SUBMIT and we will let you know via text when to proceed to the door for a temperature check.

Signature *

Within 24 hours of appt Covid-19 Screener

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