Name *

First Name

Last Name

Phone

(###)

###

####

Have you been in contact with someone who has tested positive for COVID-19? *

Yes

No

Have you experienced any of the following symptoms in the past 48 hours: *

Fever or chills

Cough

Shortness of breath or difficulty breathing

Fatigue

Muscle or body aches

Headache

Loss of taste or smell

Sore throat

Congestion or runny nose

Nausea or vomiting

Diarrhea

I am NOT experiencing any symptoms of COVID-19.

I acknowledge that the answers I have provided are true and accurate. *

Yes