Name *

First Name

Last Name

Phone *

(###)

###

####

Have you been tested for COVID-19 and are waiting to receive test results? *

Yes

No

In the past 14 days, have you been in close proximity to anyone who was experiencing any COVID-19 symptoms, has been exposed to someone with symptoms, or has experienced any COVID-19 symptoms since your contact? *

Yes

No

Have you traveled outside the U.S. in the past 30 days? *

Yes

No

Have you been in personal contact with a person infected with Coronavirus or who has traveled to an area with widespread and ongoing transmission of Coronavirus in the past 30 days *

Yes

No

Have you had a fever (99.5°+)? *

Yes

No

Coughing? *

Yes

No

Sore Throat? *

Yes

No

Difficulty Breathing? *

Yes

No

Muscle Aches? *

Yes

No

Stomach Pain? *

Yes

No