Full Name

Phone Number

Email Address

Date of Visit

In the past 14 days, have you experienced any of the following symptoms? Fever or chills Cough Shortness of breath Loss of taste or smell Other

Have you tested positive for COVID-19 in the past 14 days? Yes No

Have you had close contact with anyone with confirmed COVID-19 in the past 14 days? Yes No

Have you traveled internationally in the last 14 days? Yes No