Spanish (Latin America)
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Date of birth
Have you been in close contact with a confirmed case of coronavirus with the last 14 days?
Are you currently experiencing or have you experienced within the last 14 days; shortness of breath, fever, cough or cold symptoms?
Please specify details of the symptoms
Have you been in a Hospital, Nursing home or Inpatient Rehab facility within the past 2 weeks?
Are you on Dialysis?
Emergency Contact Name
Emergency Contact Phone
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