COVID-19 questions Question Title * 1. What is your name? OK Question Title * 2. When is your appointment? Date / Time Date Time AM/PM - AM PM OK Question Title * 3. Have you had a cough? Yes No OK Question Title * 4. Have you had a fever? Yes No OK Question Title * 5. Have you been around anyone exhibiting these symptoms within the past 14 days? Yes No OK Question Title * 6. Are you living with anyone who is sick or quarantined? Yes No OK Question Title * 7. If you answered YES to any of the questions above, please explain and/or call Kelly Cook @ 502-287-3000. OK Question Title * 8. Do you have any concerns or suggestions for us? OK DONE