By checking this box, I hereby pledge, promise and represent that all information provided below is true and accurate. By checking this box, I also understand, acknowledge and agree that this COVID-19 Self-Screening Checklist is not a substitute for professional medical advice, diagnosis or treatment and that I should always consult a medical professional when needed.

Name *

Name must match with your appointment to receive services.

First Name

Last Name

Phone Number *

(###)

###

####

Fever (body temperature over 100.3°F) without taking any fever reducing medication(s): *

Yes

No

Cough or runny nose: *

Yes

No

Loss of smell or loss of taste: *

Yes

No

Muscle aches, chest pain or sore throat: *

Yes

No

Shortness of breath, dizziness, chills or headache: *

Yes

No

Have you or anyone in your household been in close contact with someone known to have Coronavirus (COVID-19) in the last 14 days? (Close contact defined as being less than 6’ apart for more than 10 minutes.) *

Yes

Not to my knowledge

Have you or anyone in your household been asked to self-isolate or quarantine by a medical professional or a local public health official? *

Yes

No