In Person Appointment Form Name First Last What is the date of your appointment? MM slash DD slash YYYY What is the time of your appointment? : Hours Minutes AM PM AM/PM Do you have a fever of over 100 degrees or have you had one in the last 72 hours? Yes No Have you been exposed within the last 14 days to anyone who tested positive for COVID-19? Yes No Are you having any COVID-19 symptoms such as loss of taste or smell, fever, coughing, shortness of breath, unexplained gastrointestinal problems or chills? Yes No Have you traveled on public transportation other than normal daily commuting within the last 14 days? Yes No Δ
