Patient’s Name

Last Name

First Name

Patient’s Date of Birth

Email Address

COVID-19 Screening: Parent Declaration

Please select “Yes” or “No”

Over the last 48 hours have you/your child experienced any of the following symptoms?
Fever, cough, sore throat, shortness of breath, vomiting, diarrhea, loss of taste or smell

YesNo

In the last 14 days have you/your child been in close contact (6 feet or closer for at least 15 minutes) with anyone who had a confirmed COVID positive test?

YesNo

Are you/your child isolating or quarantining because of an exposure to a person with COVID-19?

YesNo