COVID19 Visitor Screening Haga clic aquí para ver esta página en español. Please only use this form if your case manager has given you an appointment for Sunday, Jun 04, 2023. If your appointment is for a later date, please complete this form on the date you will be coming in . We cannot accept walk in clients, so if you do not have an appointment from your case manager, please contact that person to get one. If you are not sure who your case manager is, please call us at 212-822-8300. If you do not have an active case with us, we are completing all our intake via our hotline at 929-415-8745. Please call us at 929-415-8745 for an intake so you can be assigned a case manager. Date Name * First Last Email (we will use this to send you a receipt) Phone (we will only use this information if we need to tell you about an exposure to COVID-19) * Have you had any Covid-19 symptoms in the past 14 days (including new or worsening cough, shortness of breath, difficulty breathing, fever of above 100.4F, chills, muscle pain, sore throat or new loss of taste and smell)? * Yes No Have you had close contact (within 6 feet) with confirmed or suspected cases of Covid-19 in the past 10 days? * Yes No Have you had BOTH doses(One dose of Johnson & Johnson) of the Covid-19 vaccine? * Yes No On what date did you get the SECOND dose or DOSE of Johnson & Johnson?? * Have you had a positive test result for Covid-19 in the past 14 days? * Yes No Have you traveled internationally in the last 10 days? * Yes No Are you FULLY VACCINATED? * Yes No On what date did you get the SECOND dose? * My responses to the above questions are true. * Yes No I agree to follow NMIC’s visitor guidelines for PPE (like wearing masks) and social distancing (like staying 6 feet away from others). * Yes No Result * Result * Comment ClientID (STAFF ONLY) Submit Δ
