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Westview Assisted Living
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Visitor Screening Form
Each visitor must fill out one form to document time of entry, symptoms and vaccine status. Thank you for helping us keep our community safe!
Visitor Name:
(Required)
Date:
(Required)
Time of Entry:
(Required)
Who are you visiting?
(Required)
Answer the questions below:
What is your temperature?
(Required)
Do you have a cough?
(Required)
Yes
No
Have you experienced shortness of breath?
(Required)
Yes
No
Do you have a headache?
(Required)
Yes
No
Have you lost your taste or smell?
(Required)
Yes
No
Have you had exposure to COVID-19 in the last 14 days?
(Required)
Yes
No
Have you traveled outside of the U.S.A?
(Required)
Yes
No
Have you had your COVID-19 vaccine?
(Required)
Yes
No
I agree to abide by the following visitation guidelines:
(Required)
I agree to the visitation guidelines.
Fully vaccinated visitors wear your mask throughout the hallways and in office spaces.
Fully vaccinated visitors may remove their mask while in the resident rooms.
Unvaccinated visitors wear your mask at all times. Unvaccinated visitors no eating or drinking.
Everyone use hand sanitizer before entering and exiting the resident room.
You may enjoy your visit outside if the weather permits.
Buffalo Lake Healthcare Center
Buffalo Lake Area Housing
Westview Assisted Living
Therapy
F.R.E.E.
