Inquire Now

Health Self Reporting Form

Please fill out this questionnaire if you have any reason to believe you have been exposed to the COVID-19 virus, are experiencing symptoms or tested positive for COVID-19. Once you submit the form, you will be taken to a page with more information.

If you have been exposed to the COVID-19 virus, are experiencing symptoms or tested positive for COVID-19, please respond to the following. You will be given more information after submitting the form.

If you are experiencing symptoms of the COVID 19 Virus or have been diagnosed with the virus, please respond to the following.

(If you do not have a primary care provider in the area, call LaVista CHI clinic at 402-717-9500 and they will provide guidance, and if necessary, be prepared to meet any patient with COVID- 19 procedures.)