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Covid-19 Form
COVID19 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?
Sore throat
Cough
Chill
Body aches for unknown reason
Shortness of breath
Loss of sense of smell
Loss of sense of taste
Fever at or greater than 100 degrees F
Other
Other
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
*
If you are human, leave this field blank.
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