COVID-19 (Coronavirus) Online Assessment

Submitted assessments will be reviewed by an advanced practice nurse or physician and you will be emailed next steps during clinic hours.

Patient Information




Symptoms & Additional Information

Do you currently have these symptoms?





Shortness of Breath


In the last 14 days, did you have close contact with a suspected or laboratory-confirmed COVID-19 (Coronavirus) patient?


Are you healthcare professional?


Are you over the age of 65?


Do you have any of the following medical conditions?

  • Heart disease
  • Lung disease
  • Kidney disease
  • Diabetes
  • Chemotherapy, HIV, or other immune disorders such as lupus, rheumatoid arthritis
  • Long term use of prednisone or other immunosuppressive medications
  • Organ transplantation or absence of spleen
  • Pregnancy

Select “Yes” if you have any of the listed medical conditions.