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COVID Client/Visitor Screening Questions

Please respond to the questions below.

Name*
First Last
Email*
Phone*
Firm member you are scheduled to meet with?*
Date of Firm Meeting*
MM slash DD slash YYYY
Time of Firm Meeting*

: Hours

Minutes

AM/PM
COVID Vaccinated?*
- Yes
- No
Do you have any of the following symptoms?*
- Fever
- Repeated shaking with chills
- Shortness of breath (not severe)
- Muscle pain
- Cough
- Chills
- Headache
- Sore throat
- New loss of taste or smell
- No, I have none of these symptoms
Have you been instructed to quarantine?*
- Yes
- No
Have you been in contact with anyone who has been told to quarantine within the past 14 days?*
- Yes
- No

Are you ill, or caring for someone who is ill?*
- Yes
- No
In the two weeks before you felt sick, did you:*
- Have contact with someone diagnosed with COVID-19?
- Have contact with someone showing symptoms of COVID-19?
- Live or visit someone who is quarantined due to COVID-19?
- Have traveled outside of the area?
- Not applicable.
You stated you traveled outside of the area, please tell us where.*
Have you received a positive COVID-19 test?*
- Yes
- No
When was the positive test results received?
MM slash DD slash YYYY
In the past two weeks have you traveled outside of Maryland to a state with a positivity rate of 10% or higher?*
- Yes
- No

For the safety of our employees and other visitors, we generally cannot allow access to our office if any of the answers to the above questions are "yes." Limited exceptions may be made for fully vaccinated individuals who have traveled domestically outside of Maryland. Please click submit to send your responses to our office prior to your scheduled appointment. Thank you.

Δ

Name*
First Last
Email*
Phone*
Firm member you are scheduled to meet with?*
Date of Firm Meeting*
MM slash DD slash YYYY
Time of Firm Meeting*

: Hours

Minutes

AM/PM
COVID Vaccinated?*
- Yes
- No
Do you have any of the following symptoms?*
- Fever
- Repeated shaking with chills
- Shortness of breath (not severe)
- Muscle pain
- Cough
- Chills
- Headache
- Sore throat
- New loss of taste or smell
- No, I have none of these symptoms
Have you been instructed to quarantine?*
- Yes
- No
Have you been in contact with anyone who has been told to quarantine within the past 14 days?*
- Yes
- No

Are you ill, or caring for someone who is ill?*
- Yes
- No
In the two weeks before you felt sick, did you:*
- Have contact with someone diagnosed with COVID-19?
- Have contact with someone showing symptoms of COVID-19?
- Live or visit someone who is quarantined due to COVID-19?
- Have traveled outside of the area?
- Not applicable.
You stated you traveled outside of the area, please tell us where.*
Have you received a positive COVID-19 test?*
- Yes
- No
When was the positive test results received?
MM slash DD slash YYYY
In the past two weeks have you traveled outside of Maryland to a state with a positivity rate of 10% or higher?*
- Yes
- No

For the safety of our employees and other visitors, we generally cannot allow access to our office if any of the answers to the above questions are "yes." Limited exceptions may be made for fully vaccinated individuals who have traveled domestically outside of Maryland. Please click submit to send your responses to our office prior to your scheduled appointment. Thank you.

Δ

mcmillan metro P.C.

7811 Montrose Road • Suite 400 • Potomac, MD • 20854 • (301) 251-1180

MARYLAND
VIRGINIA
WASHINGTON DC

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