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

Thanks for submitting!

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