Covid Screening Please answer these additional questions to help ensure the safety of our patients and staff. "*" indicates required fields Name* First Last Date of Birth*MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Phone*Choose a Location*Please select from listFairway, KansasLeawood, KansasLiberty, MissouriRaytown, MissouriAre you currently experiencing any:Coughing* Yes No Shortness of breath* Yes No Fever* Yes No Chest pain or tightness* Yes No Have you traveled out of state in the last 14 days?* Yes No Have you been in contact with anyone who has traveled out of state in the last 14 days?* Yes No Have you tested positive for COVID-19 in the last 14 days?* Yes No Have you been in contact with anyone that has tested positive for COVID-19 in the last 14 days?* Yes No Reason for your visit and/or additional informationCAPTCHAConsent I agree to the privacy policy. Δ