COVID19 Screen
Name
*
First Name
Last Name
E-mail
*
Phone Number
*
-
Area Code
Phone Number
HAVE YOU HAD ANY OF THE FOLLOWING ONSET SYMPTOMS: FEVER > 100 F, CHILLS, REPEATED SHAKING WITH CHILLS, BODY ACHES, HEADACHES, SORE THROAT, LOSS OF TASTE AND/OR SMELL, COUGH, OR SHORTNESS OF BREATH
*
Yes
No
HAVE YOU HAD CONTACT WITH A PERSON THAT HAS BEEN FORMALLY OR POTENTIALLY DIAGNOSED WITH COVID19 IN THE PAST 14 DAYS? *
*
Yes
No
Have You Received Your COVID Vaccine? (Please provide proof on day of appointment)
*
Yes - Both shots
Yes - Only the 1st Shot
No (We will provide service if the answers above are "No")
DO YOU AGREE TO OUR TERMS AND CONDITIONS?
*
Yes
No (Service will be refused)
Signature
Clear
TODAY'S DATE
*
-
Month
-
Day
Year
Date
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