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First Name

Last Name

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Health status



Are you feeling generally well?

If no, do you have any of the following symptoms: persistent cough, fever chills, sore throat, shortness of breath, lack of taste, lack of smell?

In the last 14 days, to your knowledge, have you been in close contact with anyone who tested for Covid-19 or is awaiting a test result?

Have you attended/visited a healthcare facility treating patients for Covid-19 in the last 30 days?

Are you awaiting test results of a Covid-19 test?

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