Pre-Treatment COVID-19 Check

Date*
MM slash DD slash YYYY
Name*
First Last
I understand the above symptoms and affirm that I, as well as my household members, do not currently have, nor have we experienced the symptoms listed within the last 14 days.*
- Yes
- No
I affirm that I, as well as all household members, have NOT knowingly been exposed to anyone diagnosed with COVID-19 within the last 30 days.*
- Yes
- No
I affirm that I, as well as all household members, have NOT traveled outside the Country, or to any City/State that IS or has been considered a “hot spot” for COVID-19 infections within the last 14 days.*
- Yes
- No
I affirm that as of today’s date listed above that I do not have a pending COVID-19 test.*
- Yes
- No
Signature*
Clicking this button acts as a signature to the answers provided above.