Coronavirus – (COVID-19) 

Active Self Assessment Form

This Self-Assessment is designed for existing patients of Envision Medical Group and each of its practices.

Please fill out each of the questions below.   When done, click the Send button to submit the form.

You will be contacted by a representative from your physician’s office for additional information or further action.

In the meantime, please feel free to check our continuously updated page with the latest news and information on Coronavirus-(COVID-19) and what you can do to protect yourself and your family..

Coronavirus - (COVID-19) - Self Assessment Form v31920

If you answered yes to one or more of these questions and have shortness of breath/respiratory symptoms:

  • Stay at home and call your physician’s office.  A patient representative will take your information and have a healthcare provider contact you to discuss next steps.
  • You may also schedule a telehealth visit with your doctor.  Please call your doctors office.
  • If you believe your symptoms are life threatening, go to the nearest hospital emergency department.  we recommend that you call the emergency department immediately so the staff can provide you with arrival instructions.
  • For more information, contact our offices or your local county health department.