COVID-19 Pre-screening Form
Date of Birth
Street Address Line 2
State / Province
Postal / Zip Code
Primary Phone Number
Alternate Phone Number
These questions must be answered honestly under penalty of law. An answer of YES does not exclude you from treatment. Please answer YES or NO to each of the following questions:
Do you have a fever or above normal temperature?
Have you experienced shortness of breathe, difficulty breathing, cough, or flu-like symptoms?
Have you recently lost or had a reduction in your sense of smell?
Do you have a sore throat?
Have you been in contact with someone who has tested positive for COVID-19?
Have you tested positive or had any symptoms of COVID-19?
Have you been tested for COVID-19 and are awaiting results?
Have you traveled outside the United States by air or cruise ship in the past 14 days?
Do you have a weakened immune system?
Do you have diabetes?
Do you have asthma or COPD?
Explain any YES answers in the box below:
Signature: By typing your name in the box below, you acknowledge that your answers you provided are true and accurate to the best of your knowledge:
Please verify that you are human
Should be Empty: