COVID-19 Visitor Screening (Downstairs)

Your Full Name *

Phone Number *

Email Address

Have you experienced a fever of 99 degrees Fahrenheit (37.2 degrees Celsius) or greater, chills, a cough, loss of taste or smell, or shortness of breath within the past 10 days? *

Yes
No

In the past 10 days, have you tested positive for COVID-19 using a saliva test or a nose or throat swab? *

Yes
No

In the past 14 days, have you knowingly been in close contact (within 6 ft) with anyone who tested positive for COVID-19? *

Yes
No

Is your body temperature HIGHER than 99 degrees Fahrenheit (37.2 degrees Celsius)? Please take your temperature w/ our thermometer at the front desk. *

Yes
No

Regardless of your answer to the above question, please indicate the temperature you measured, include unit if not Fahrenheit: *

COVID-19 Visitor Screening (Downstairs)

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