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COVID Questions
First Name
Last Name
Phone
Date of Service
Time of Appointment
12:00 AM
12:15 AM
12:30 AM
12:45 AM
01:00 AM
01:15 AM
01:30 AM
01:45 AM
02:00 AM
02:15 AM
02:30 AM
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06:00 AM
06:15 AM
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06:45 AM
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07:15 AM
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07:45 AM
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08:45 AM
09:00 AM
09:15 AM
09:30 AM
09:45 AM
10:00 AM
10:15 AM
10:30 AM
10:45 AM
11:00 AM
11:15 AM
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11:45 AM
12:00 PM
12:15 PM
12:30 PM
12:45 PM
01:00 PM
01:15 PM
01:30 PM
01:45 PM
02:00 PM
02:15 PM
02:30 PM
02:45 PM
03:00 PM
03:15 PM
03:30 PM
03:45 PM
04:00 PM
04:15 PM
04:30 PM
04:45 PM
05:00 PM
05:15 PM
05:30 PM
05:45 PM
06:00 PM
06:15 PM
06:30 PM
06:45 PM
07:00 PM
07:15 PM
07:30 PM
07:45 PM
08:00 PM
08:15 PM
08:30 PM
08:45 PM
09:00 PM
09:15 PM
09:30 PM
09:45 PM
10:00 PM
10:15 PM
10:30 PM
10:45 PM
11:00 PM
11:15 PM
11:30 PM
11:45 PM
01:10 AM
Who will be performing your service?
Do you have any of the following symptoms?
Fever or Chills
Shortness of Breath / Difficulty breathing
Cough or Sore throat
Unexplained Body Aches
Changes in taste or smell
No, I'm showing no symptoms
Have you been in Close Contact or Cared for someone diagnosed with COVID-19
Yes
No
Is anyone in your household currently sick?
Yes
No
Have you traveled in the last 14 days?
Yes, Internationally
Yes, Outside of Utah but not to a COVID hotspot
Yes, Outside of Utah and in COVID hotspot (New York, New Jersey, etc.)
No, I have not traveled
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