Precautions

COVID-19 Questionnaire

Please fill out the following form to help us keep you safe.

First Name

Last Name

Email Address

Have you traveled outside the U.S. in the past 30 days?

No

Yes

Have you traveled to a U.S City/State with reported cases of Coronavirus in the past 30 days?

No

Yes

Have you had a fever (99.5 +) in the last 48 hours?

No

Yes

Have you experience any: Coughing, Sore Throat, Difficulty Breathing, Muscle Aches, or Stomach Pain? In the last 48 hours.

No

Yes

Elaborate on any of the above if yes

Initials

Today's Date

I declare that the info I’ve provided is accurate & complete

Thanks for submitting!

bottom of page