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COVID-19 Clientele Questionnaire
What’s your first name?
What’s your last name?
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?