Pre Visit Certification. Please respond truthfully to the following options Name First Name Last Name Phone (###) ### #### Email Address Address 1 Address 2 City State/Province Zip/Postal Code Country During the last 14 days, did you, or any of your companions have close contact with someone with symptoms suggesting COVID-19 infection ? Yes No During the last 14 days, have you or any of your companions had a diagnostic test for COVID-19 with a positive result? Yes No During the last 14 days, have you had one or more of the following symptoms Fever Dry Cough Loss Of Smell Loss of Taste Fatique Sore Throat Difficulty Breathing Yes No Thank You!
