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COVID 19 Release Form

COVID-19 Screening

Respiratory Illness Signs & Symptoms

For the safety of our patients and team members please complete the following screening

 

Patient Name______________________________ DOB____/____/____ Temp__________

Patient Name______________________________ DOB____/____/____ Temp__________

Patient Name______________________________ DOB____/____/____ Temp__________

Patient Name______________________________ DOB____/____/____ Temp__________

 

Do you / or a family member:

  1. Have a fever (100.4F or greater)?                                                                               YES       NO

 

  1. Have a cough (Not related to allergies)?                                                                      YES       NO

 

  1. Have shortness of breath?                                                                                          YES       NO

 

Have you / or a family member:

 

  1. Been in close contact with any person suspected to have COVID-19?                           YES       NO

 

  1. Been in close contact with any person with a confirmed COVID-19?                             YES       NO

 

  1. Traveled outside of Colorado within the past 14 days?                                                YES       NO

 

  1. Traveled outside of the United States within the past 30 days?                                 YES       NO

 

  1. Traveled to the mountains in Colorado since March 7th, 2020?                                     YES       NO

 

 

Thank you for completing this form. We appreciate your cooperation and patience during this time.

 

Parent Signature__________________________________________ Date_______________________