Covid-19 Screening FormPlease fill out this form prior to your appointment! Name * First Name Last Name Date MM DD YYYY Are you experiencing any symptoms of Covid-19? (Sore throat, cough, chills, shortness of breath, loss of taste or smell, muscle aches, prolonged headache etc.)? Yes No Are you a close contact of someone who has tested positive for or is suspected to have Covid-19 in the last 10 days? Yes No Are you meant to be isolating while awaiting test results, after travel or otherwise? Yes No Have you or anyone in your household or in your close contacts tested positive for Covid-19 within the last 10 days? Yes No Thank you!