5. COVID-19 Screening

5. COVID-19 Pre-visit Screening
Name *

First Name Last Name
Date of birth: *

Month Day Year
Date
Have you been fully vaccinated for COVID-19? (received all recommended doses) *

No Yes
Did you receive your final dose of the vaccine within the last 14 days? *

No Yes
Please list the details for each of your vaccinations *
Do you have any of the following new symptoms in the past 48 hours? *

No Symptoms Fever/Temperature of 100.4 or above Chills Cough Shortness of breath Muscle Aches Sore throat Diarrhea Loss of taste or smell
Have you been diagnosed with COVID-19 in the past 21 days? *

No Yes
Have you been in close contact with another person diagnosed with COVID-19 in the past 14 days? *

No Yes
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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