Turkey Creek | COVID Screening

1

Name* This field is required.

First Name

Last Name

2

Phone Number* This field is required.

Area Code

Phone Number

3

Have you received both Covid-19 vaccinations?

YESNO

4

Have you been told to quarantine/isolate by a health care provider or the health department within the last two weeks?* This field is required.

YESNO

5

Have you had face-to-face contact for 15 or more minutes with someone who has COVID-19 within the last two weeks?* This field is required.

YESNO

6

Are you feeling ill/ and or experiencing any of the following? Cough, Fever (prior to use of fever-reducing medications), Shortness of breath, New loss of sense of taste/smell, Vomiting, Diarrhea, or Chills (within the past 24 hours)* This field is required.

YESNO