Name *

First Name

Last Name

Phone *

Country

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Is your temperate 100F (38C) or higher? *

Yes, it is 100F or higher

No, it is below 100F

Have you traveled within a state with significant community spread of COVID-19 for longer than 24 hours within the past 14 day *

Yes, I have traveled within a state with significant community spread of COVID-19 for longer than 24 hours within the past 14 day

No, I have not traveled within a state with significant community spread of COVID-19 for longer than 24 hours within the past 14 day

Select any of the following that applies to you: *

I have tested Positive for

I have come into close contact with someone who tested Positive or had symptoms of COVID-19 in the last 14 days

Neither of the above

Are you experiencing any of the following as new or worsening symptoms: *

Shortness of breath or difficulty breathing

Cough

Body aches/ muscle pain/ chills

Sore throat

New loss of taste and/ or sense of smell

Fatigue/ generally feel sick or unwell (malaise)

New or worsening headache

Nausea, vomiting or diarrhea

New skin lesions

None of these