You can always press Enter⏎ to continue
Covid-19 Questionnaire
Update: This form only needs to be filled out once.
6
Questions
START
1
Full Name
*
This field is required.
First Name
Last Name
Previous
Next
Submit
Press
Enter
2
Email
If you would like a copy of this form, please enter email here:
example@example.com
Previous
Next
Submit
Press
Enter
3
Have you been vaccinated against COVID-19?
*
This field is required.
Only answer “Yes, Fully” if it has been at least 2 weeks since the last required dose. (2 weeks since the second dose or booster of Pfizer or Moderna, or 2 weeks since the J&J)
Yes, Fully.
Have had one dose of a two dose vaccine
Yes, and have had booster shot.
No
Previous
Next
Submit
Press
Enter
4
Terms & Conditions
*
This field is required.
Please read and acknowledge the following agreement, and check the "I Agree" box to continue. Date and signature required on following pages.
Previous
Next
Submit
Press
Enter
5
Today’s Date
-
Date
Month
Day
Year
Previous
Next
Submit
Press
Enter
6
Signature
*
This field is required.
Clear
Previous
Next
Submit
Press
Enter
Should be Empty:
Question Label
1
of
6
See All
Go Back
Submit
