DUGhealth COVID-19 Pre-Screening General Health Form

COVID-19 Pre-Screening General Health Form

Thank you for choosing Doctors United Group. The safety of our clients, team members and the communities we serve is our overriding priority. As the coronavirus disease 2019 (COVID-19) outbreak continues to evolve and spreads globally, we are closely monitoring the situation and will periodically update company guidance based on current recommendations from the CDC and World Health Organization. To prevent the spread of COVID-19 and reduce the potential risk of exposure to our clients and team members, we are conducting a simple screening questionnaire. Your participation is important to help us take precautionary measures to protect you and everyone in this building.
Testing Location: *
Date *

Month Day Year
Date
Full Name *

First Name Last Name
Phone Number *
Email
A copy of this document will be emailed to you.
Date of Birth *

Month Day Year
Date
Address

Street Address

Street Address Line 2

City State

Zip Code

**By Signing this document you are certifying that, to the best of your knowledge, all information is correct as indicated and you are healthy to work on site.
Signature *
Miami Dade

1498 NW 54th Street Suite C | Miami, FL 33142 | 305.603.8200

714 NW 62nd Street | Miami, FL 33150 | 786.485.3885

Hialeah

2150 W 76th Street Suite 100 | Hialeah, FL 33016 | 305.530.8949

4212 W 16th Avenue | Hialeah, Fl 33012 | 305.821.552

Homestead

974 Old Dixie Highway | Homestead, FL 33030 | 786.349.4290

Broward

3215 NW 10th Terrace | Fort Lauderdale, FL 33309 | 954.530.3586

Orlando

3300 W Colonial Dr Suite 142 | Orlando, FL 32808
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