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* 1. What is your name?

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* 2. When is your appointment?

Date
Time

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* 3. Have you had a cough?

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* 4. Have you had a fever?

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* 5. Have you been around anyone exhibiting these symptoms within the past 14 days?

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* 6. Are you living with anyone who is sick or quarantined?

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* 7. If you answered YES to any of the questions above, please explain and/or call Kelly Cook @ 502-287-3000.

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* 8. Do you have any concerns or suggestions for us?

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