Covid-19 Form

Name *

First

Last *

Last

Email *

Phone *

(e.g. XXX-XXX-XXXX)

Date of Birth *

Have you or anyone in your household had any of the following symptoms in the last 14 days?

Please provide further information *

Have you ever been tested for COVID-19? *

Yes

No

Please provide testing dates and results *

Have you or anyone in your household been exposed to COVID-19 in the past 14 days? *

Yes

No

Please provide further information *

Have you or anyone in your household visited or received treatment in a hospital, nursing home, long-term care, or other healthcare facility in the past 14 days? *

Yes

No

Please provide further information *

Have you or anyone in your household traveled on an airplane or cruise ship in the past 14 days? *

Yes

No

Please provide further information *