"*" indicates required fields Thank you for taking a minute to complete this important screening form PRIOR to your visit to Simply Great Health. Please answer the following questions, then press submit.Name* Dr.MissMr.Mrs.Ms.Prof.Rev. Prefix First Last Phone*Mobile*Email* Do you have any symptoms of COVID-19 such as cold/flu, fever, loss of taste or smell, cough, runny nose, sore throat, shortness of breath?* Yes No Do you have a current diagnosis of COVID-19 or are you waiting for a test result?* Yes No Have you been in contact with anybody with COVID-19?* Yes No Have you been at any Locations of Interest?* Yes No Comment CAPTCHACommentsThis field is for validation purposes and should be left unchanged. Δ
