Please complete this form in its entirety.
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Your First & Last Name
I am a(n):
Do you have one or more of the following symptoms?
Shortness of breath
New loss of taste or smell
runny nose (excluding seasonal allergies)
New unexplained fatigue
Muscle or body ache
Nausea or vomitting
In the past 14 days have you been in direct contact with anyone who has tested positive for Covid 19?
Have you or anyone in your household been asked to quarantine?