Age 3-15: A parent or legal guardian needs to fill out this form and accompany the patient to visit.
Age 16-17: A parent or legal guardian needs to fill out this form.
All fields are required unless marked as optional.
Have you experienced any of these symptoms? (Select any that apply)
Do you have any of the following medical conditions? (Select any that apply)
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I acknowledge that I have answered these questions truthfully to the best of my knowledge. I understand that I must perform my own nasal swab or bring someone to do it for me.