Rutherford Physical Therapy Clinic COVID-19 Screening
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Full Name *
TODAY'S DATE *
Do you have a fever? *
Required
Do you have a cough? *
Required
Do you have runny nose? *
Required
Do you have a sore throat? *
Required
Do you have any shortness of breath or difficulty breathing? *
Required
Have you returned to Canada from outside the country (including the USA) in the past 14 days? *
Required
Did you have close contact with someone who has a probable or confirmed case of COVID-19? *
Required
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