Patient Screening Form

Patient's Name

Patient's Age

Email Address

Phone Number

Preferred Contact Method

Email Phone

1. Do you have a fever or have felt hot or feverish anytime in the last two weeks?

Yes No

2. Do you have any of these symptoms: Dry cough, Muscle Aches, Shortness of breath, Difficulty breathing, Sore throat, or Runny nose?

Yes No

(2b) If 'Yes' to above, please provide more detail:

3. Have you experienced a recent loss of smell or taste?

Yes No

4. Have you been in contact with any confirmed COVID-19 positive patients, or persons self-isolating because of a determined risk for COVID-19?

Yes No