Schedule an In-Person Visit

Resident's Name*

First Last

Your Name*

First Last

Your Email*

Preferred Day for Visit

Preferred Time for Visit (9am to 5pm only)

: HH

MM

Have you been exposed to anyone under evaluation for exposure to Covid-19?*

Yes
No

Have you been around anyone that has been sick in the last 7 days?*

Yes
No

Do you currently or in the previous 72 hours have had any of the following symptoms: fever, cough, shortness of breath, headache, body aches, sore throat, diarrhea or nausea/vomiting?*

Yes
No

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Sherwood Healthcare Center