COVID-19 Screening

In order to keep everyone safe, including you, this COVID-19 screening must be completed the same day of the event with Mother's Heart Birthing Services. Everyone attending the event must complete the screening.

Name(Required)
MM slash DD slash YYYY
Do you have two of any of these symptoms?(Required)
*If these new Upper Respiratory Infection (URI) are due to normal allergies, do not answer yes. If yes, please contact Mother's Heart Birthing Services at 517-348-3283.
Do you have any symptoms of:(Required)
If yes, please contact Mother's Heart Birthing Services at 517-348-3283.
Have you been in close physical contact* in the last 14 days with:(Required)
*Close contact is being within 6 feet of an infected person for a cumulative total of 15 minutes over a 24 hour period. ** If you are fully vaccinated (all doses at least 2 weeks ago) answer NONE If yes, please contact Mother's Heart Birthing Services at 517-348-3283.
Have you returned from international travel within the past 10 days*(Required)
*If you are fully vaccinated, full series at least two weeks ago, answer NO If yes, please contact Mother's Heart Birthing Services at 517-348-3283.
In accordance with CDC regulation, Mother's Heart Birthing Services requires mask wearing for any attendee regardless of vaccine status unless the event takes place outside(Required)