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* 1. What is your contact information?

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* 2. In the past 14 days, have you experienced or experiencing the following:

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* 3. In the past 14 days, have you experienced a high  temperature/fever over 99 degrees?

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* 4. Have you been diagnosed with COVID 19?

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* 5. Have you been knowingly exposed to COVID 19?

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* 6. Choose the type of screening in you would like:

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* 7. What type of sex do you have? (Choose the type of sex that you've had. This helps us test in the correct areas of possible exposure.)

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* 8. Do you inject drugs?

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* 9. Would you like to receive a text or email regarding your next appointment or other events Joseph H. Neal Health Collaborative has coming up?

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* 10. What day would you like schedule for your screening?

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