Have you experienced any of the following symptoms of COVID-19 within the last 14 days? Cough, sore throat, shortness of breath, muscle pain, runny nose, sneezing, loss of smell with or without feverYesNo

Have you been in close contact or have been in isolation with a suspected or confirmed case of COVID-19 in the last 14 days?YesNo

Have you travelled internationally in the last 14 days?YesNo

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Date

I, verify that the answer I provided on this form to be truthful and honest. It is my responsibility to notify the office if any of the answer changes before my appointmentYesNo

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