Name

First Name Last Name

Date of Birth

Date

Phone Number

Please enter a valid phone number.

Email

example@example.com

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Gender

Female Male Other

Passport Number

For Travelers

Race

Please Choose the one Describe You the Best

Are you pregnant or may be a pregnant?

Yes No

Do you regularly use tobacco or nicotine products (e.g. cigarettes, e-cigarettes, vapes, hookah, etc.)

Yes No

Have you possibly been exposed to the Coronavirus in the past 2 weeks?

Yes No

Do you live, work or have visited a place where COVID-19 is widespread.

Yes No

Do you suffer from any following conditions?

High blood pressure Heart disease (e.g. previous heart attacks, heart failure, etc.) Diabetes Overweight or obesity Kidney disease or Dialysis Previous stroke or other neurological condition affecting my ability to cough Liver disease Lung disease NONE OF THE ABOVE

Do you have a condition that weakens my immune system or makes it harder to fight infections

Are you taking one of these medications?

Steroids Chemotherapy Immunosuppressants NONE OF THE ABOVE

Have you had any of the following symptoms since December 2019?

Currently, are you experiencing any of the symptoms described in previous questions?

Yes No

Have you been in close proximity (within 6 ft.) to someone who is sick?

Yes No

Date

Signature

Clear

Covid-19 Antigen Intake Form