* Required Information
Patient Screening For COVID-19
It matters to us that you are regularly checked during this pandemic to ensure that you are safe at all times. Please fill and submit the screening form by clicking here. Call us at 214-988-1488 to report any incidence.
Have you travelled internationally within the last 14 days to countries with sustained community transmission?
Yes
No
Do you have any of the following signs or symptoms of a respiratory infection, such as a fever, cough, and sore throat?
Yes
No
In the last 14 days, have you had contact with someone with or under investigation for COVID 19, or are ill with respiratory illness?
Yes
No
Do you live in a community where community-based spread of COVID-19 is occurring?
Yes
No
To your knowledge, have you had contact with anyone who has traveled to countries with sustained- community transmission?
Yes
No
Have you been on a cruise or in another setting with confined crowds in the last 14 days?
Yes
No
Have you visited someone with confirmed COVID-19?
Yes
No
In the last 14 days, have you had contact with someone who is under investigation for or has a confirmed diagnosis of COVID 19, or is ill with respiratory illness?
Yes
No
Name of Agency Representative
*
Agency Representative Signature
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Patient Name
*
Patient Signature
Clear