First Name*Last Name*Phone*Email* Do you have a coughYesNoHave you come in contact with any confirmed COVID-19 positive patients in the last 14 days?YesNoAre you experiencing shortness of breath or difficulty breathing?YesNoAre you experiencing other flu-like symptoms, such as gastrointestinal upset, headache, or fatigue?YesNoAre you over the age of 60?YesNoDo you have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?YesNoHave you traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your location)YesNoCAPTCHAPhoneThis field is for validation purposes and should be left unchanged.