COVID-19 Screening Form

Salutation:
Patient's Name: Patient's Name: First Last
Date: Date: / MM / DD YYYY
Do you have a temp of 100 degrees Fahrenheit or
higher?
Have you had close contact or cared for someone
with COVID in the past 14 days?
Have you returned from travel outside of the
United States by cruise ship or river boat in the
past 14 days?
Have you been directed to self quarantine by a
healthcare provider?
Have you been directed to self quarantine by the
County or State Department of Public Health?
Have you had COVID in the last 14 days?
Draw your signature into the box below.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.

Dr. Donald W. Hogan D.D.S