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COVID-19 Screening Questions

  1. TH-Huguley Hospital Fort Worth South - color

  2. TH - Neighborhood Care and Wellness Burleson - color

  3. Burleson - City - Solid -Maroon

  4. Para asistencia en la detección de COVID en español, por favor llame al 817-551-2762.

  5. This is the number we will contact you at, please ensure you will have the ability to answer at this number.

  6. This is the email we will contact you at, please ensure you will have the ability to check this email address.

  7. Gender

  8. Have you previously tested positive for COVID-19?

  9. Does the patient have insurance?

  10. Has your doctor provided a lab order?

  11. Screening Questions

  12. Have you been exposed to a confirmed positive patient?*

  13. The CDC defines exposure as within 6 feet for more than 15 minutes.

  14. Are you symptomatic?

  15. Are you employed in the healthcare industry?

  16. Are you pregnant?

  17. Leave This Blank:

  18. This field is not part of the form submission.