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CALL US: 336 | 382 | 9722

COVID-19

Health Screening

First Name

Last Name

I am not experiencing the symptoms: fever, cough, sore throat, fatigue, congestion

No one in my household is experiencing the symptoms: fever, cough, sore throat, fatigue, congestion

I have not been advised to currently quarantine AND no one in my household is currently under quarantine

I am not waiting on Covid-19 test results AND no one in my household is waiting on Covid-19 test results

I have not been exposed AND no one in my household has been exposed in the last 14 days

I haven’t been in close contact with a Covid-19 patient in the last 14 days

Date

I declare that the info I’ve provided is accurate & complete

Thanks for submitting!

ADDRESS

210 N Main Street Suite 124
Kernersville, NC 27284

CONTACT

Tel: 336-382-9722

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