Forms • St. Joseph County, IN • CivicEngage

Visitation Request

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1) Name of the Portage Manor Resident you'd like to request a visit with?*

2) What time/date are you requesting visitation*

Have you experienced any symptoms related to COVID-19 today or tested positive for COVID-19 in the past 14 days?

Yes

Have you been exposed to anyone with COVID-19 or symptoms of COVID-19?

Yes

REMINDER: Wear a face mask during your visit.
You will need to wear a face mask for your entire visit and
you also must ensure social distancing by allowing at least 6 feet distance from all residents during your visit.

Please check here that you understand these visitation policies

Please provide your contact information to complete request*

* indicates required fields.

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