Pre-COVID Visitation Questionnaire - Alderson Convalescent Hospital

Visitor:*

Resident's Name:*

First Last

Relationship to Resident:*

Your Email:*

Your Phone:*

Have you previously tested positive for COVID? If yes, when?*

Did you receive the COVID vaccine? If yes, when did/will you receive your second dose?*

Are you or anyone in your household showing any signs or symptoms of COVID?*

Have you or anyone in your house had any exposure to someone with a confirmed case of COVID in the last 14 days?*

Do you agree to all of the below questions? Check all of the questions to show you agree with them.*

Today's Date:*

Name of person completing the form?*

First Last

This will count as your legal signature of confirmation.

Email

This field is for validation purposes and should be left unchanged.