COVID-19
Please Fill Out Before Starting Your Services
Full Name
*
First Name
Last Name
Phone Number
*
Check the conditions that apply to you
*
History of Heart Failure
Pulmonary Hypertension
History of Kidney Failure
Peripheral Edema
Any Type of Bleeding Disorder
Currently on Blood Thinners (other than aspirin)
NONE
Please check all that apply to you. Have you experienced any of the following in the last 5 Days?
*
Chest pain
Respiratory Issues
Difficulty Breathing
Fever
Dry Cough
Exhibiting any other symptoms related to COVID-19
Vomited in the last 12 hours
NONE
Are you currently taking any medication?
*
Yes (please list):
No
Do you have any medication allergies?
*
Yes (please list):
No
Not Sure
Submit
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