Please Complete and Submit

We look forward to seeing you in person. Please complete the following screening and attestation form as part of our in person meeting requirements.

Thank you!

Name *

First

Last

Today's Date *

Email *

Phone

Have you experienced any of the following symptoms of COVID-19 within the past 48 hours? *

• Fever, chills, muscle or body aches
• Cough, shortness of breath or difficulty breathing
• Fatigue
• Headache
• New loss of taste or smell
• Sore throat, congestion or runny nose
• Nausea, vomiting, or diarrhea
• I have not experienced any of these symptoms

Have you tested positive for COVID-19 in the past 10 days?

• No
• Yes

Are you currently awaiting results from a COVID-19 test?

• No
• Yes

In the past 10 days have you been in close proximity to anyone who has been confirmed positive with COVID-19?

• No
• Yes

Thank you. Please click submit below and no further action is required.

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