Covid-19 Check in

Full Name*

Date of Service*

Date of Service

E-mail*

Phone Number*

Have you been to one of the COVID-19 affected countries in the last 14 days?

Yes
No

Have you been in close contact with a confirmed case of coronavirus?

Yes
No

Are you currently experiencing symptoms (cough, shortness of breath, fever)

Yes
No

By submitting I hereby confirm that the information I have given above is true, and that I will comply with the terms and conditions outlined above.

Yes

I agree to terms & conditions. *

You can submit this form only once.

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