As providers of essential medical treatments, we aim to provide a safe environment. To ensure the safety of both our patients and staff, it is critical that the information submitted in this form is as accurate as possible.
What is your COVID-19 vaccination status?
El Paso County is vaccinating people age 16 and older.
FOR MORE INFORMATION ON THE COVID-19 VACCINE: Call 2-1-1 Monday through Friday, 8 a.m. to 5 p.m. -Free, confidential vaccine referrals. Available in multiple languages.
TEXT “vaccine” (FOR ENGLISH) OR “vacuna” (FOR SPANISH) TO 667873 to get contact information for your preferred vaccine provider
COVID-19 VACCINE HOTLINE
Available 24 hours a day, 7 days a week.
Have you experienced any of the following symptoms in the past 7 days?
In the past 7 days have you had close contact with anyone who has been diagnosed with COVID-19 or suspected to have COVID-19?
In the past 7 days have you visited any other cities/states/countries?
Please list the cities/states/countries you visited.
(For example: I went to San Antonio – Friday, Saturday, and Sunday)
In the past 7 days have you had any visitors (Family, friends, etc) from out of town?
Please list the place they visited from and the type of interaction
(For example: Family members from Denver stayed the weekend)
In the past 7 days have you been to any gatherings or events which more than 5 people were in attendance?
Please list the even and the type of interactions
(For example: I went to a concert where I was seated 6 feet away from people)
In the past 7 days have you visited any of the following places: