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Are you currently experiencing any of the following symptoms?
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Have you received the COVID-19 Vaccine?
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Have you previously tested positive for COVID-19?
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Have you been out in public that could potentially expose you to COVID-19 in the last 14 days?
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Do you work in an office with other co-workers or are you a student that attends classes in a classroom?
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Is it possible you had close contact with someone with a confirmed case of COVID-19?
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Are you a resident in a special setting where the risk of COVID-19 transmission may be high?
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(Initial) patient acknowledgement to have answered questions truthfully to the best of knowledge
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Print Name
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Signature
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