Covid-19 Patient Screening Form Help us protect you and your family by filling out this quick, secure Covid-19 screening form. Name(Required) First Last Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary Phone Number(Required)✓ Valid number ✕ Invalid numberEmail(Required) These questions must be answered honestly under penalty of law. An answer of YES does not exclude you from treatment. Please answer YES or NO to each of the following questions:Do you have a fever or above normal temperature?(Required) Yes No Do you have a runny nose?(Required) Yes No Have you recently lost or had a reduction in your sense of smell?(Required) Yes No Do you have a sore throat?(Required) Yes No Have you been in contact with someone who has tested positive for COVID-19?(Required) Yes No Have you tested for COVID-19?(Required) Yes No Do you have a weakened immune system?(Required) Yes No Explain any YES answers in the box below:Signature: By typing your name in the box below, you acknowledge that your answers you provided are true and accurate to the best of your knowledge:(Required) PhoneThis field is for validation purposes and should be left unchanged.