COVID-19 Screening Form

Thank you for visiting Gardens of Getshemani. Please fill out the following COVID-19 screening form before entering our office.

Are you experiencing any of the following symptoms? •*
• Fever
• Cough or worsening chronic cough
• Shortness of breath
• Sore throat
• Runny nose
• Loss of smell or taste
• Headache
• Fatigue
• Diarrhea
• Loss of appetite
• Nausea and vomiting
• Stuffy nose
• Conjuctivitis (pink eye)
• Dizziness, confusion
• Abdominal pain
• Skin rashes or discoloration of fingers or toes
- Yes
- No
Have you been diagnosed with COVID-19 in the last 14 days?*
- Yes
- No
Are you waiting for laboratory test results for COVID-19?*
- Yes
- No
Within 14 days, have you been in contact with anyone diagnosed with COVID-19?*
- Yes
- No
Are you living with anyone that is infected or quarantined due to COVID-19?*
- Yes
- No
Notification*
I will notify Gardens of Gethsemani if I contract COVID-19 within the next 14 days.*
You may not enter the office. Please call to reschedule your appointment.
Your Information
Name*
First Last
Email

Leave blank if none.
Phone*
Signature*
By signing below, I confirm that the information I have given is accurate and complete.

You may not enter the office. Please call to reschedule your appointment.