Get In Touch Nulla tempus sollicitudin dui, ut vehicula lacus porta vel. Duis urna ligula, luctus at feugiat a lacinia ut sem. Quisque sit amet ipsum ac odio malesuada convallis. Childs Name Do you have any of the following symptoms? (Fever, cough, difficulty breathing, soar throat, trouble swallowing, runny nose, loss of taste or smell, not feeling well, nausea, vomiting, diarrhea) Do you have any of the following symptoms? (Fever, cough, difficulty breathing, soar throat, trouble swallowing, runny nose, loss of taste or smell, not feeling well, nausea, vomiting, diarrhea) Yes No Have you been in close contact with someone who is sick or has confirmed COVID-19 in the past 14 days? Have you been in close contact with someone who is sick or has confirmed COVID-19 in the past 14 days? Yes No Does your child have a fever greater than 37.8c and or chills? Does your child have a fever greater than 37.8c and or chills? Yes No Have you returned from travel in the past 14 days? Have you returned from travel in the past 14 days? Yes No Date ”Send
