VISITOR HEALTH SCREEN

Pleasant View requests your help to reduce community risks to the spread of COVID-19. For the residents, team members, and other visiting family members and guests, please complete the following health screen questions.

The completion of this health screen is required by the Illinois Department of Public Health.
Before each scheduled visit, the completion of this health screen is mandatory before Pleasant View is able to welcome scheduled guests onto the campus.

* All fields and answers are required:
 

How many visitors for this scheduled visit?
(If two, second visitor must also complete this form)

Select One

In the last 14 days, have you experienced any of the following symptoms of COVID-19?

Fever

Thank you.
Your health screen has been delivered.