Name
What is the Date and Time of your Appt?
:  
1. Have you received your final COVID shot and has it been at least 14 days since that shot?
2. Are you having any COVID-19 symptoms such as loss of taste or smell, fever over 100 degrees, coughing, shortness of breath, unexplained gastrointestinal problems or chills?
3. Have you been exposed within the last 14 days to anyone who tested positive for COVID-19?
4. Have you traveled outside the United States in the last 14 days?
What was the date of your return to the United States:
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