In the past 14 days, have you or anyone in the household, knowingly had
contact with a person who has been exposed to, been diagnosed with, in
the process of being tested, or has tested positive for COVID-19?
In the past 14 days, have you or anyone in the household, travelled internationally,
been on a cruise, or visited any domestic location subject to a CDC travel
If any of your information should change prior to services rendered, please contact our Service Division at firstname.lastname@example.org.