Patient Screening Form

Full Name:

E-mail Address

Are you immunocompromised and/or live in a highest-risk congregate care setting?

Do you have any of these symptoms? Choose any or all that are new, worsening and not related to other known causes or conditions.
(check all that apply)

Have you been told (by a doctor, health care provider, public health unit, federal border agent, or other government authority) that you should currently be quarantining, isolating or staying at home?

In the last 10 days, have you tested positive for COVID-19 on a laboratory-based PCR test, rapid molecular test, rapid antigen test or other home-based self-testing

Consent and Authorization