Covid-19 Questionnaire and Consent

    ALL FIELDS ARE REQUIRED:

    Your email

    Have you experienced any NEW symptoms in the past week:
    * fever or chills * cough * shortness of breath or difficulty breathing * fatigue * muscle or body aches * headache * loss of taste or smell * sore throat * congestion or runny nose * nausea or vomiting * diarrhea *

    Have you been in close contact within the last 14 days with:
      • Anyone who has been exposed to Covid 19 or has a confirmed case of Covid-19?
      • Anyone who has symptoms consistent with Covid-19?

    Date

    Your name to represent your signature