Covid questionnaire
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Email *
Name *
Date of birth  (XX/XX/XX) *
Are you or anyone in your household experiencing a cold or any flu-like symptoms including fever, cough, shortness of breath, nasal congestion, runny nose or sore throat? *
Are you experiencing any nausea, vomiting or diarrhea? *
If you answered yes to any of the above questions, please use the space below to explain.
Please use the space below to explain. express any other pertinent information regarding COVID-19. *
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