COVID-19 Screening Form

COVID-19 Screening
Full Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Phone Number

Area CodePhone Number
Email
example@example.com
Please check off any of the symptoms that your are currently experiencing:

CoughShortness of Breath
Please check off any of the symptoms that your are currently experiencing:

FeverChillsRepeated shaking with chillsMuscle painHeadacheSore throatNew loss of taste or smell
Type a question

YesNo
Count Checks
You have selected symptoms that are indiciative of a potential COVID-19 infection. Please call DOCS Medical Group to schedule an appointment appointment: 203-874-3682. Please also make sure to submit this form.
Should be Empty: