COVID-19 Questionaire

What’s your first name?

What’s your last name?

Email

Phone

Have you experienced any cold or flu-like symptoms in the last 14 days (to include fever, cough, sore throat, respiratory illness, difficulty breathing)?

Have you been around anyone exhibiting flu-like symptoms within the past 14 days?

Have you had close contact with or cared for someone diagnosed with COVID 19 within the last 14 days?

COVID-19 Clientele Questionnaire