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Covid Screening Tool

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Covid Screening Tool

Basic form to get patient information before they come in for a COVID test

Page 1

Please fill out the following information

Email*

First Name*

Last Name*

Date of Birth*

Select date

Gender*

Race*

Ethnicity*

Address*

City*

10.

State*

11.

Zip Code*

12.

Phone Number*

13.

Email Address*

Description:This Covid screening tool is designed to collect basic patient information before they come in for a COVID test. It helps healthcare professionals to quickly assess the patient's symptoms and determine the next steps. The form is easy to fill out and can be completed in just a few minutes.

Protecting the health and safety of patients and healthcare workers is a top priority during the COVID-19 pandemic. This Covid screening tool is a basic form that collects patient information before they come in for a COVID test. The form includes questions about the patient's symptoms, travel history, and exposure to COVID-19. The information collected helps healthcare professionals to quickly assess the patient's risk level and determine the next steps. The form is easy to fill out and can be completed in just a few minutes. By using this screening tool, healthcare facilities can reduce the risk of exposure to COVID-19 and ensure that patients receive the appropriate care.

First Name*

Last Name*

Date of Birth*

Select date

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Full Name*

Address*

Phone Number*

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First Name*

Last Name*

Date of Birth*

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Full Name*

Date of Birth*

Phone Number*

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Full Name*

Age*

Gender*

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