Name
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E-mail
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Phone Number
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Have you tested positive for COVID-19?
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Yes
No
Do you currently have symptoms of COVID-19?
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Yes
No
Are you under a mandatory isolation?
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Yes
No
Have you had close contact with someone diagnosed with COVID-19 or with symptoms?
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Yes
No
Are you currently experiencing, or have experienced recently within the last 3 weeks?
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I Have No Symptoms
Coughing
Fever
Shortness of Breath
Loss of Taste/Smell
Sore Throat
Headache
Fatigue
Gastrointestinal (GI) Symptoms
Chills
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