Compassionate Care Visitor Pre-Screening

Presence of any symptoms: (check any that apply)

Have you been in close contact with anyone who has tested postive or suspected postive for COVID-19 in the last 14 days? *
Please follow the instructions in the Resident Connections Policy to schedule your visit. This form does not serve as your appointment reservation. This form must be filled out and submitted on the date prior to your scheduled visit. Please ensure that you are filling out the pre-screening form for the type of visit you have scheduled. Failure to comply may result in your visit being cancelled without notification of the cancellation. You will receive an email confirmation after this form has been submitted. *