5. COVID-19 Screening

5. COVID-19 Pre-visit Screening
Screening Result

POSITIVE SCREENINGNEGATIVE
Name*

First NameLast Name
Date of birth: *

MonthDayYear
Date
My appointment is with:*
Appointment Date*

MonthDayYear
Date
Have you been fully vaccinated for COVID-19? (received all recommended doses)

NoYes
Did you receive your final dose of the vaccine within the last 14 days?

NoYes
Please list the details for each of your vaccinations
Do you have any of the following new symptoms in the past 48 hours?*

No SymptomsFever/Temperature of 100.4 or aboveChillsCoughShortness of breathMuscle AchesSore throatDiarrheaLoss of taste or smell
Have you been diagnosed with COVID-19 in the past 10 days?*

NoYes
Have you been in close contact with another person diagnosed with COVID-19 in the past 10 days?*

NoYes
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---PLEASE READ---

Based on your responses you must call the office immediately!

Ninth Street Internal Medicine: (215) 440-8681

MDVIP Patients: (215) 940-9925

We need to speak to you as soon as possible to determine if an in office visit is appropriate and will be safe for our other patients, staff, and the community
Please Note

Our office requires that all patients wear a mask or face-covering at all times while visiting our office, regardless of their individual vaccination status.

This is to ensure the safety of all of our patients and staff members as per CDC guidelines.
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5. COVID-19 Pre-visit Screening