COVID Form | L'Ash Rebel

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COVID-19/Flu & Common Cold

First Name

Last Name

Email

Phone

Have you had or have been exposed to anyone with COVID-19 or Flu like symptoms in the last 10 days?

Are you experiencing any Flu-like, Cold, or any contagious symptoms?

Have you tested positive for COVID-19 or the Flu in the past 10 days?

Check any symptoms you may have experienced in the last 48hrs

Coughing

Sneezing

Feverish

Headache

Sore Throat

Body/Muscle Aches

Congestion/Runny Nose

NONE

Thank you for your honesty and cooperation!

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