First Name*:

Last Name*:

Have you experienced any of these symptoms in the past 48 hours*:

  1. Fever or chills
  2. Cough
  3. Shortness of breath or difficulty breathing
  4. Fatigue
  5. Muscle or body aches
  6. Headache
  7. New loss of taste or smell
  8. Sore throat
  9. Congestion or runny nose
  10. Nausea or vomiting

Yes   No   

Have you traveled or attended a large gathering in the last 14 days OR had exposure to a confirmed positive case of COVID-19?

Yes   No