Check In – Health Screening Check Out Check In - Health Screening 1Step 12Step 2 Select(Required)Staff / GuestStaffGuestThis field is hidden when viewing the formStaffName(Required) Staff First Staff Last Car Vehicle ModelLocation(Required)SylmarEventThis field is hidden when viewing the formDate(Required)MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920This field is hidden when viewing the formTime(Required) Hours : Minutes AM PM AM/PM This field is hidden when viewing the formGuestName(Required) First Last Appointment(Required)YesNoLocation(Required)San FernandoSylmarEventAppointment With(Required)This field is hidden when viewing the formDate(Required)MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920This field is hidden when viewing the formTime(Required) Hours : Minutes AM PM AM/PM Are you currently experiencing any of the following symptoms? Check all that apply: Coughing Shortness of Breath Difficulty Breathing Fever Chills/Body Aches (includes Headaches) Sore Throat Recent loss of Taste or Smell Weakness or Fatigue rash In the last 3 days, did you care for, or have contact with someone diagnosed with COVID-19?(Required) Yes No Is anyone who lives with you currently ill?(Required) Yes No Have you been in contact with anyone who has recently been tested for Covid-19, but hasn’t yet received their result?(Required) Yes No Signature(Required)
