Pre-appointment Health Screening

Pre-appointment Health Screening

For the health and safety of our community, declaration of illness is required. Be sure that the information you'll give is accurate and complete. Please get immediate medical attention if you have any of the COVID-19 signs.
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email
example@example.com
Date & Time of Appointment

MonthDayYear
Date
Hour MinutesAM/PM Option

Have you or anyone in your household had any of the following symptoms in the last 21 days: *

	Yes	No
sore throat
cough
chills
body aches for unknown reasons
shortness of breath for unknown reasons
loss of smell
loss of taste
fever at or greater than 100 degrees Fahrenheit

Have you or anyone in your household been tested for Covid-19 in the past 14 days?*

YesNo
Have you or anyone in your household visited or received treatment in a hospital, nursing home, long-term care, or other healthcare facility in the past 30 days?*

YesNo
Have you or anyone in your household traveled abroad in the past 21 days?*

YesNo
Areas Visited and Dates of Travel:*
Have you or anyone in your household traveled on a cruise ship in the last 21 days?*

YesNo
Areas Visited and Dates of Travel:*
Have you or anyone in your household cared for an individual who is in quarantine or is a presumptive positive or has tested positive for COVID-19?*

YesNo
Do you have any reason to believe you or anyone in your household has been exposed to or acquired COVID-19?*

YesNo
To the best of your knowledge have you been in close proximity to any individual who tested positive for COVID-19?*

YesNo
Acknowledgement:

“I certify that I have answered truthfully and that I am not placing the employees and representatives of Goodwin, Lademan and Associates at risk of COVID-19 infection by participating in this in person meeting.”
Signature*

Clear
Please verify that you are human*
Should be Empty: