Coronavirus Screening Form

A clinical intake tool that screens patients for COVID-19 symptoms and exposure risk before an in-person or telemedicine appointment.

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Full Name*

First Name

Last Name

Phone Number*

Chart Number*

Do you have any of the following symptoms?*

Fever Cough Sore throat Shortness of breath Loss of taste or smell Fatigue

Have you been in contact in the last 14 days with anyone experiencing these symptoms?*

Yes No

Have you been in contact with anyone who has since tested positive for COVID-19?*

Yes No

Have you travelled abroad in the last 1-2 months? Where did you go?

Reason for Appointment:*

Advice:*

Customer Service Representative filling out this form:*

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