COVID From
Please take a minute to fill in the following info
First Name
Last Name
Email
Phone Number
Have you have a fever within the last 14 days?
Yes
No
Have you been in contact with an individual who tested positive for COVID-19 within 14 days?
Yes
No
In the past 24 hours, have you had anyone in your home with a fever of 100 degrees or more?
Yes
No
Are you experiencing shortness of breath, coughing, fever or other symptoms often associated with the flu?
Yes
No
Have you tested positive for COVID-19 within 14 days?
Yes
No
Please specify anything we should know about:
Your Signature
*
Clear
Today's date
Submit
Powered by