Contact Information
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Primary Phone Number
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Additional Information
Family’s method of transportation to the hospital or our house?
Will you have a vehicle on premises?
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Has anyone in the guest party been asked to self-quarantine due to COVID-19 in the past 10 days?
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In the last 48 hours, has anyone in the guest party had: cough, shortness of breath, difficulty breathing, new loss of smell/ taste, sore throat, runny nose/ congestion and/or GI symptoms?
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In the last 48 hours, has anyone in the guest party had: a fever of 100.0 degrees fahrenheit or higher, body aches, and/ or headache?
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Is anyone in the guest party waiting on a COVID test result not related to preadmission testing for the patient?
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Has anyone in the guest party had a positive COVID test in the last 10 days?
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Does anyone in the guest party need a wheelchair accessible room?
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Is there any additional information you would like to add?