COVID-19 Screening – Office Use COVID-19 Screening Office Use First Name:* Last Name:* Date:* Time:* Temperature:* Are you experiencing any COVID-19 symptoms?*Are you experiencing any COVID-19 symptoms? Yes No Have you been exposed to anyone that has been diagnosed with COVID-19?*Have you been exposed to anyone that has been diagnosed with COVID-19? Yes No Consent* I agree the above information is correct. EmailThis field is for validation purposes and should be left unchanged.
