COVID19 Patient and Visitor Screening

Please complete the following survey questions within 24 hours of your visit or appointment at Cambridge Memorial Hospital.
* indicates required field

Please enter your legal FIRST name: *


Please enter your legal LAST name: *


1. Please enter your phone number (do not enter spaces/dashes in the phone number):
Mobile/Cellular phone preferred. Enter the 10 digit number only. *


2. Please enter your email address:
Entering your email, will allow us to send you confirmation of the survey after completion, to present upon arrival to hospital. We will not use your email address for any other purpose.