Covid 19 Form

If you are planning on visiting one of our clinics please fill out the form below to save time when you arrive.




 CMOH Order 05-2020 legally obligates any person who has the following cough, fever, shortness of breath, runny nose, or sore throat (that is not related to a pre-existing illness or health condition) to be in isolation (quarantine) for 10 days from the start of symptoms, or until symptoms resolve, whichever takes longer. If they are exhibiting any of these symptoms, it is suggested they complete the COVID-19 Self-Assessment online tool to determine if they should be tested.


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Please note: Any individual who has gone in for testing on their own volition as an asymptomatic individual does not need to indicate that.
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