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Covid Screening Form

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COVID-19 Form - STEP
If you develop symptoms prior to your appointment please call us to re schedule.
First Name*
Last Name*
Do you have a cough?*
- Yes
- No
Do you feel short of breath?*
- Yes
- No
Do you have a high temperature?*
- Yes
- No
Do you have a sore throat?*
- Yes
- No
Have you been in contact with a patient with COVID19 in the last 14 days?*
- Yes
- No
Have you been in a nursing home in the last 14 days?*
- Yes
- No
Administrative-email

COVID-19 Form - STEP