Wellness Form

Name*

First Last

Email*

Phone*

Do you have a cough?*

Do you have a fever now or have you in the past 14-21 days?*

Have you come in contact with any confirmed COVID-19 positive patients in the last 14 days?*

Are you experiencing shortness of breath or difficulty breathing?*

Are you experiencing other flu-like symptoms, such as gastrointestinal upset, headache, or fatigue?*

Have you experienced recent loss of taste or smell?*

Are you over the age of 60?*

Do you have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?*

Have you traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your location)*