Covid-19 Questionnaire
Name
*
First Name
Last Name
Are you experiencing any of the following symptoms? Cough, Shortness of breath, or fever
*
Cough
Shortness of breath
Fever
None of the above
Have you been in contact with someone who had the flu, respiratory illness, or Coronavirus in the last 14 days?
*
Yes
No
Have you traveled outside of PA in the last 14 days? If so, please contact our office.
*
Submit
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