COVID-19 Screening Form

940 Town Centre Drive, Suite B, Medford OR 97504 | (541) 772-5939

Effective May 1, 2020, all clients must complete this COVID-19 screening form.

Do you have any of the following: Fever over 100 degrees, chills, or sweats? Shortness of breath? Cough?

Yes

Are you under observation for possible COVID-19 or have you been asked by local health authorities to self-quarantine for COVID-19?

Yes

Is anyone in your household under observation for possible COVID-19 or been asked by local health authorities to self-quarantine for COVID-19?

Yes

In the last two weeks, have you been in contact with someone who has a confirmed case of COVID-19?

Yes

If the answer is “yes” to any of these questions, please call your health care provider and do not book an appointment at this time.

Signature

Your typed name above indicates a "no" answer to all these questions

Date Signed

Your information will be encrypted.