"*" indicates required fields Untitled* Untitled* Email* Do you have a fever or have you experienced a fever within the past 14 days?** Yes No Have you experienced a recent onset of respiratory problems, such as a cough or difficulty in breathing within the past 14 days?** Yes No Have you, within the past 14 days, traveled outside the country?** Yes No Have you come into contact with a person with confirmed 2019-nCoV infection within the past 14 days?** Yes No Have you come into contact with people from confirmed cities, surrounding areas or people from a neighborhood with a recent documented fever or respiratory problems within 14 days?** Yes No Untitled I certify that the information submitted in this form is true and correct to the best of my knowledge. I further understand that any false statements may result in denial or revocation of treatment or service.Communications through our website or via email are not encrypted and are not necessarily secure. Use of the internet or email is for your convenience only, and by using them, you assume the risk of unauthorized use.CAPTCHA
