Patriot Check-In Form

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Patriot Check-In
Sore Throat? *
Cough? *
Shortness of Breath? *
Chills? *
Repeated shaking with Chills? *
Muscle pain? *
Headache? *
New loss of taste or smell? *
Travel outside of the U.S in the last 14 days? *
If yes, please fill out the field below
Close contact with COVID-19 patient(s)? *
Have you worked in another healthcare setting that has confirmed COVID-19 patient(s)? *
If yes, please fill out the field below
*