Mpox Contact Form
Name of Patient
First Name
Last Name
Contact Person's Phone Number
Please enter a valid phone number.
Name of Health Department
Symptoms
Fever
Chills
Swollen lymph nodes
Exhaustion
Muscle aches and backache
Headache
Sore throat
Nasal congestion
Cough
Other
Symptoms Time Range
1-3 days
3-5 days
5-10 days
Other
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