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Facial Consent For Covid 19 -Form Fill

Section One
Q1

Name

First Name
Q2

Name

Last Name
Q3

Birth Date

Month
Q4

Birth Date

Day
Q5

Birth Date

Year
Q6

Email
Q7

Phone Number
Q8

Address

Street Address
Q9

Address

Street Address Line 2
Q10

Address

City
Q11

Address

State / Province
Q12

Address

Postal / Zip Code
Q13

A weak immune system can put you at greater risk for contracting COVID-19. Please select the ones that apply.
Q14

Have you tested positive for COVID-19?
Q15

Have you been tested for COVID-19 and are awaiting results?
Q16

Have you been in contact with someone who has tested positive for COVID-19?
Q17

Have you traveled abroad by air or cruise ship in the past 14 days?
Q18

Please select the signs or symptoms that you are currently experiencing or have experienced within the last 15 days.
Q19

Further Comments
Q20

Date

Date
Q21

Signature