GENERAL INTAKE FORM

First name

Last name

Email

Phone

COVID-19 Pre-Screening

Are you currently waiting on the results of a COVID-19 test?

Yes

No

Have you experienced any of the following symptoms in the past 48 hours:

Have you had any signs of a fever in the past 24 hours or had a temperature that has elevated 100.0F or greater?

Yes

No

Within the past 14 days, have you been in close physical contact with anyone who test positive with cov-19?

Yes

No

This is required, this is for your protection and mine.

ID