Name *

First Name

Last Name

Have you or someone that lives in your household had any travel within the past 14 days? *

Yes

No

Have you had any signs or symptoms of a respiratory infection, such as a fever, cough, shortness of breath, sore throat, chills, repeated shaking with chills, muscle pain, loss of taste? *

Yes

No

In the last 14 days have you had contact with someone with a confirmed diagnosis of COVID-19, or who is under assessment for COVID19, or has been ill with respiratory illness? *

Yes

No

Do you consider yourself as being in the high-risk category for COVID-19 as defined by the CDC? High Risk - Older adult or someone with a serious chronic medical condition, or anyone with a chronic disease such as heart disease, diabetes, lung disease, immunecompromised disease, liver disease, chronic kidney disease, are receiving treatments that may compromise one’s immune system? *

Yes

No

Is your temperature < 100.4F or above? *

Yes

No

I understand and will adhere social distancing guidelines and will wear a mask. (Masks and gloves will be available for those that need. Gloves are optional) *

Yes