COVID-19 Visitor Screening

Type your name stating that the information on this form is true.

1. In the last few days, have you experienced any of the following symptoms
not explained by a chronic condition?

• Cough
• Shortness of breath or difficulty breathing
• Fever or Chills (More than 99.9 F)
• Congestion or runny nose
• Fatigue
• Muscle or Body aches
• Headache
• Sore throat
• New loss of taste or smell
• Diarrhea
• Nausea or Vomiting

YES NO

Please enter numbers only

2. In the last 14 days, have you been exposed to a person who is positive for
COVID-19?

YES NO

If you answered YES to any of the above questions, you do not fit the criteria to visit. We apologize for any inconvenience this may have caused.

If you begin to experience symptoms and have been potentially exposed, please notify the Beacon Hill COVID-19 Hotline at 616-734-9544.

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Get in touch

• • • •

(616) 608-8236

1919 Boston Street SE
Grand Rapids, MI 49506

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