You must have JavaScript enabled to use this form. I am a(n) - Select -Admissions Visitor(s)Community Member/Vendor Your Information Name First Last What is your temperature? Guest 1 Guest Name Guest First Name Guest Last Name What is their temperature? Guest 2 Guest Name Guest First Name Guest Last Name What is their temperature? Do you or your guest have any of the following (please check all that apply) Fever (100.4 or greater) or chills Cough Shortness of breath Difficulty breathing Body aches Headache New loss of taste or smell Sore throat None of the above Have you or your guest been in close contact (within 6’) with someone who has a laboratory confirmed Covid-19 diagnosis within the past 14 days? - Select -YesNo If yes, have you been tested? - Select -YesNo Date Result - Select -PositiveNegative Submit
