COVID Questionnaire

I have not been diagnosed with or cared for someone diagnosed with COVID-19 in the past two weeks.

I have not shown symptoms of COVID-19 or come in close contact with anyone exhibiting these symptoms in the past two weeks.

I have not traveled outside of my immediate daily routine for the past two weeks.

I do not have a cough, fever, chills, shortness of breath, or loss of taste or smell.

If I begin to show symptoms of COVID-19 within the next two weeks, I will contact my vet hospital.

I will follow all posted rules to keep myself, the staff and those around me safe.

Name

First Last

Date

Phone

CAPTCHA