Has the patient or anyone in the family (household) tested positive for COVID-19?*

Has the patient or anyone in the family (household) tested positive for COVID-19? and are waiting for the result?*

Does the patient or anyone in the family (household) have any of the following respiratory syptoms? Fever, Sore Throat, Cough, Shortness of Breath?*

Has the patient or anyone in the family (household) recently lost your sense of smell or taste?*

Even if you don't currently have any of the above symptoms, has the patient or anyone in the family (household) experienced any of these symptoms in the last 14 days?*

Has the patient or anyone in the family (household) been in contact with someone who has tested positive for COVID-19 in the last 14 days?*

Has the patient or anyone in the family (household) traveled outside the United States by air or cruise ship in the past 14 days?*

Has the patient or anyone in the family (household) traveled outside the United States by air, bus or train within the past 14 days?*

Patients Name(s)*

Date of Birth*

Select Date*

Relationship to Patient*