COVID19 Screening
Please answer the following questions to the best of your ability.
Email *
Name *
Phone Number *
Do you currently have any of the following respiratory symptoms? *
Required
Do you currently have any of the following symptoms? *
Required
Have you traveled within the last 2 weeks? *
Have you knowingly been exposed to COVID19 in the last 2 weeks? *
I understand that I will be asked to use hand hygiene and wear a mask during my appointment. *
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