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ESG HEALTH ASSESSMENT - Please complete this form prior to each visit at ESG.
Name *
Email *
Address *
Phone number
(a) knowingly been in close contact in the past 14 days with anyone who has tested positive for COVID-19 or who has or had symptoms of COVID-19; *
(b) tested positive for COVID-19 through a diagnostic test in the past 14 days; *
(c) experienced any symptoms of COVID-19 in the past 14 days; *
(d) traveled within a state with significant community spread of COVID-19 for longer than 24 hours within the past 14 days. *
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