First Name* Last Name* Phone*Email* Do you have a cough Yes No Have you come in contact with any confirmed COVID-19 positive patients in the last 14 days? Yes No Are you experiencing shortness of breath or difficulty breathing? Yes No Are you experiencing other flu-like symptoms, such as gastrointestinal upset, headache, or fatigue? Yes No Are you over the age of 60? Yes No Do you have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders? Yes No Have you traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your location) Yes No CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.