COVID-19 Vaccine Questionnaire Before we schedule your vaccine(s) For the safety of other customers and our employees, let's first get these familiar questions out of the way. Please answer this brief COVID-19 Questionnaire for the person being scheduled. *All fields are required. In the past 14 days, have you tested positive for COVID? * Yes No In the past 14 days, have you come into contact with some who has tested positive for COVID? * Yes No Do you currently have fever, chills, cough, shortness of breath, difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, nausea, vomiting, or diarrhea? * Yes No You are not eligible at this time We are unable to schedule a vaccine for you at this time due to your potential risk for spreading COVID-19. Please contact your primary care provider to discuss vaccine options available to you. We offer daily testing. Would you like to get tested? Link To Schedule COVID Test If you are human, leave this field blank. Submit colleen2021-03-17T19:13:58-04:00