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COVID-19 Screening Questionnaire
Have you had a temperature over 100.4 degrees within the past 24 hours?
Are you currently experiencing, or have you experienced in the past 14 days, any of the following symptoms? (Check all that apply)
In the past 14 days, have you been in close proximity to anyone who was experiencing any of the symptoms listed above or has tested positive for COVID-19?
Have you been tested for COVID-19 and are waiting to receive test results?

Note: The information collected on this form will be used to determine only whether you may be infected with COVID-19. Depending on your answers, your appointment may need to be rescheduled. We can reschedule appointments 72 hours after being symptom free or after 14 days of self-quarantine. 

Thanks for submitting!

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