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BVP Patient COVID Screen

We ask all patient and visitors to please complete the following COVID-19 Screening prior to visiting the clinic on the same day of your visit.  If you would like to submit our previous pdf by email, a link can be found here

Please read all questions carefully and complete and submit the appropriate attestation at the bottom of the page.

1.  Do you have any of the following symptoms which are new or worsened if associated with allergies, chronic or pre-existing conditions: 

  • Fever (>37.8 C) and/or chills
  • New onset of cough or worsening chronic cough 
  • Shortness of breath 
  • Decrease or loss of sense of taste or smell 
  • Sore throat 
  • Difficulty swallowing 
  • Headaches 
  • Unexplained fatigue/malaise/muscle aches (myalgias) 
  • Nausea/vomiting, diarrhea, abdominal pain 
  • Runny nose/nasal congestion without other known cause

2. Have you or someone you have come into close contact with tested positive for COVID-19 in the past 10 days, or have been told to be self-isolating? 

3.  If you are over 70 years of age or older, are you experiencing any of the following symptoms: delirium, unexplained or increased number of falls, acute functional decline, or worsening of chronic conditions? 

Covid-19 Health Declaration

How are you feeling today?

Thanks for submitting!

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