contact code
consult id
NAME
*
first
last
COMPANY NAME
employer or company
E-MAIL
*
PHONE NUMBER
*
-
area code
phone number
LOCATION
1301 (Deerfield)
9400 (Jacksonville)
1830 (Jacksonville)
1400 (Pennsauken)
1258 (Puerto Rico)
WHO ARE YOU VISITING?
*
name of person
REASON FOR VISIT
*
short description
CURRENT TIME
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AM/PM Option
CURRENT TEMPERATURE ABOVE 100 DEGREES
*
yes
no
WHO TOOK THIS TEMPERATURE
*
administrator's first name
SELECT ANY / ALL THAT APPLY TO YOU
*
coughing, fever and / or shortness of breath
in contact with someone who tested positive for COVID-19
been ordered to self isolate
None of the above
PLEASE GO HOME NOW
We will contact you and work out a plan for anything urgent.
Seek prompt medical attention if your illness is worsening (e.g., difficulty breathing).
If there is anything we can assist you with, feel free to contact us by email or phone.
YOU MAY CONTINUE
You MUST wear a mask to enter the premisis. No exceptions.
Maintain a 1.5 to 2 meter distance between you and everyone else.
If you need to cough or sneeze, please cover your mouth and nose with your elbow and don’t wipe your hands on anything!
Disinfect your hands with sanitizer before and after your visit.
Please do not bring children, family members and/or friends or extra co-workers with you (where possible) as the less people in contact with everyone the better.
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