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PLEASE PROVIDE THE INFORMATION BELOW ACCURATELY

PERSONAL INFO

SUBMIT AS CORRECT

COVID QUESTIONS

Have you tested positive for COVID or been vaccinated for COVID in the past 8 months?
NO
YES
Have you been in contact with someone that tested positive for COVID or attended a gathering of more than 10 people in the past 14 days?
NO
YES

Are you experiencing any of the following symptoms?

  • LOSS OF TASTE AND SMELL

  • HEADACHES

  • BODY ACHES AND PAINS
NO
YES