Customer Health Screening — COVID-19

First Name

Last Name

Do you currently have a fever of 100.4 degrees F or greater?
NoYes - No further screening is needed. The customer may not have procedure(s).

Do you have a cough or shortness of breath that began within the past 14 days?
NoYes - No further screening is needed. The customer may not have procedure(s).

In the past 14 days, have you gotten a positive result from a COVID-19 test that tested saliva or used a nose or throat swab? (not a blood test)
NoYes - No further screening is needed. The customer may not have procedure(s).

In the past 14 days, have you been in close contact (within 6 feet for at least 10 minutes) with anyone who either tested positive for COVID-19 (not a blood test) or developed symptoms of COVID-19 (fever, cough, or shortness of breath)?
NoYes - No further screening is needed. The customer may not have procedure(s).

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