*1.Name(Required.)

*2.Customer Site(Required.)

*3.Temperature(Required.)

*4.Do you have any of the following symptoms?(Required.)

Fever or chills (Temperature of 100.4 or higher)

Cough

Shortness of breath or difficulty breathing

Fatigue

Muscle or body aches

Headache

New loss of taste or smell

Sore throat

Congestion or runny nose

Nausea or vomiting

Diarrhea

None of the above