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COVID-19 Screening
Please complete the following screening questions within 24 hours of your appointment.
*
Indicates required field
Name
*
First
Last
Appointment Date/Time
*
Have you experienced any of the following symptoms in the last 48 hours?
Fever of over 100 degrees or chills
*
Yes
No
Cough
*
Yes
No
Shortness of breath or difficulty breathing
*
Yes
No
New or worsening fatigue
*
Yes
No
Muscle or body aches
*
Yes
No
Headache
*
Yes
No
New loss of taste or smell
*
Yes
No
Sore throat
*
Yes
No
Congestion or runny nose
*
Yes
No
Nausea or vomiting
*
Yes
No
Diarrhea
*
Yes
No
Are you isolating or quarantining because you tested positive for COVID-19 or are worried that you may be sick with COVID-19?
*
Yes
No
Have you been in close physical contact in the last 14 days with anyone who is known to have laboratory-confirmed COVID-19 OR anyone who has any symptoms consistent with COVID-19?
*
Yes
No
Are you currently waiting on the results of a COVID-19 test?
*
Yes
No
Have you traveled in the past 10 days?
*
Yes
No
Vaccination status:
*
Pfizer COVID-19 Vaccine: I've had one dose
Pfizer COVID-19 Vaccine: I've had both doses
Moderna COVID-19 Vaccine: I've had one dose
Moderna COVID-19 Vaccine: I've had both doses
I've had the Johnson & Johnson (Janssen) COVID-19 Vaccine
I'm not vaccinated
Submit
About
Treatment Cost
Telehealth
Patients
Portal login
Practice Documents
Medication Information
Resources
Hotlines
Referrals
>
Mental Health Referrals
Primary Care Referrals
Military & Veterans
>
Crisis Resources
Government Resources
Non-Government Resources
Therapists
Local Resources
Apps
Contact