Your name
Your email
Your phone
Date Visited label>
Do you or anyone in your household have any COVID symptoms? YesNo label>
Do you have any non-COVID related symptoms (allergies, etc)? YesNo label>
Has your temperature been above 100.3 in the past 2 days? YesNo label>
Have you been exposed to anyone with a positive case of COVID-19 recently? YesNo label>
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