Family Health Connections

 Phone: 410 -465 -5451

        443 280 2407

 M-F 9AM -  6PM

SAT-10 AM-3PM

Fax: (410)360 6459

9055 Chevrolet Drive Suite 205

Ellicott City, ​MD 21042

COVID-19 Screening Questionaire

FAMILY HEALTH CONNECTIONS

( if you don't have please enter cash or your SSN)
Location*
Have you traveled to the following countries in the past 45 days (check all that apply)*
Have you had close contact (being within 6 feet or that person for an extended amount of time) with a confirmed case of COVID-19 in the past 45 days?
Has a Public Health Official communicated that you were potentially exposed to COVID-19?
Have you had any of the following symptoms over that past 30 days? *
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On The Day of Testing For Covid -19

Dear Clients

Please be advised that our hours for  testing  Monday to Friday and 9am -5pm . Please request 


appointments during these time slots. Please indicate on your appointment request which location 


you want to be tested at.


  9055 Chevrolet drive ste 205 Ellicott  City 21042




When you arrive for testing, find a space and park in front of the building. 


 Please be sure to write your name, date of birth, address, email, phone number and more 


importantly your insurance


information CLEARLY!


Call 410 465 5451 when you are done filling out the lab slips. 



The testing is done inside your car in the parking lot.


IF YOU DO NOT HAVE INSURANCE BE SURE TO PUT YOUR SOCIAL SECURITY NUMBER ON THE LAB 


SLIP. FAILURE TO PROVIDE THESE INFORMATION WILL DELAY PROCESSING OF YOUR SPECIMEN 


AND CONSEQUENTLY DELAY YOUR RESULTS!


The nurse practitioner will see you and collect the specimen


Please NOTE the laboratory where your specimen is sent to by the lab slip you filled .

.


THANKS IN ADVANCE FOR YOUR MAXIMUM CO OPERATION



Please contact your primary care for work slips or excuse duty slips.

Thank you very sincerely!


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