1. Have you had a fever of over 100.4 within the last 24 hours?

2. Are you currently experiencing, or have you experienced in the past 14 days,  any symptoms of COVID-19?

COVID-19 Screening

3. In the past 14 days, have you been in close contact with someone who has experienced any symptoms of COVID-19 or tested positive for COVID-19?

4. Have you been tested for COVID-19 and are waiting to receive test results?



Note: The information collected on this form will be used to determine only whether you may be infected with COVID-19. Depending on your answers, your appointment may need to be rescheduled. We can reschedule appointments 72 hours after being symptom free or after 14 days of self-quarantine.