WEIR GREENBLATT PIERCE LLP COVID-19 Vaccination and Self-Screening Survey

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* 1. Name

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* 2. Date

Date of visit

Date

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* 3. Which office are you planning on visiting?

Philadelphia, PA

Haddonfield, NJ

Cherry Hill, NJ

Atlantic City, NJ

Huntingdon Valley, PA

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* 4. Are you visiting someone in the office?

Yes

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* 5. If yes, what is the name of the person you are visiting?

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* 6. Have you been fully vaccinated for COVID 19 (as defined by the CDC)?

Yes

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* 7. If you have not been fully vaccinated, have you received a negative test result for COVID-19 that was administered within 48 hours of your visit?

Yes

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* 8. Are you showing any signs of one or more of the following symptoms:

Temperature >100.4 F

Cough or sore throat

Shortness of breath

Difficulty breathing or congestion

Tiredness

Muscle or body aches

Headache

Loss of taste or smell

Nausea, vomiting or diarrhea

If you are experiencing any of the symptoms above, you may not enter our office. Please contact the person you are visiting and make alternate arrangements.

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* 9. Have you been in close proximity to, or live with, anyone who has been diagnosed with COVID-19 within the last 14 days?

Yes

If you have been exposed to COVID-19, you may not enter our office. Please contact the person you are visiting and make alternate arrangements.

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* 10. Regardless of my vaccination status, I agree to wear a mask at all times while in a Weir Greenblatt Pierce office

Yes

If you do not agree to wear a mask, you may not enter our office. Please contact the person you are visiting and make alternate arrangements.