Your Name* Phone* Email Category EmployeeClientVisitor Do you have a fever of 100 degrees or more? YesNo Are you currently experiencing any of the following? (Check all that apply) CoughShortness of breathTrouble breathingChillsMuscle PainHeadacheSore ThroatNew loss of taste or smellNone of the above Have you tested positive for COVID-19 through a diagnostic test in the last 14 days? YesNo Have you had any contact within the last 14 days with anyone who has tested positive for COVID-19 or who has symptoms of COVID-19? YesNo Have you traveled within a state with significant community spread of COVID-19 for longer than 24 hours in the past 14 days? YesNo Have you traveled internationally to a Level 2 or Level 3 country in the last 14 days? YesNo
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