JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
FM Service Screening Agreement
Freedom Mobility Service Screening Agreement Survey is for the purpose of keeping our employees and customers from the spread of COVID-19
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
Customer Name
*
Your answer
Patient's Name
*
Your answer
Customer Phone Number
*
Your answer
Do you have any signs of respiratory infection, such as fever, cough, shortness of breath or sore throat?
*
Yes
No
In the last 14 days have you had contact with
*
Anyone with a confirmed diagnosis of COVID-19?
Anyone under investigation for COVID-19?
Anyone ill with respiratory illness?
None of the Above
Required
Have you recently stayed at or visited a hospital or facility with confirmed COVID-19 cases?
*
Yes
No
Next
Clear form
Never submit passwords through Google Forms.
This form was created inside of Freedom Mobility.
Report Abuse
Forms
