Your Name *

    Your Email *

    Have you experienced a fever of 100.4 or greater in the past 14 days? *
    YesNo

    Have you received a positive result from a COVID-19 test within the past 14 days? *
    YesNo

    Have you been in contact with anyone while they had COVID-19 or symptoms of COVID-19 in the past 14 days? *
    YesNo

    In the past 14 days, have you, or someone you have been in contact with, traveled outside your state or country to an area with restrictions due to COVID-19? *
    YesNo

    In the past 14 days, have you experienced any of the following new symptoms attributed to another health condition? Select all that apply. *