COVID Tracing form

COVID – 19 Pandemic

CDC guidance for COVID-19 may be adapted by state and local health departments to respond to rapidly changing local circumstances.Due to COVID -19 there is a huge rise in number of cases from past few days. In order to eliminate any viral symptoms kindly fill the below mentioned form:

Name *

First

Last

Email *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Do you share a household? *

Have you travelled in the past 21 days? *

Please list all the places where you've been in the past 90 days. *

Have you been unwell in the past 21 days? *

Have you been exposed to someone who was unwell in the past 21 days? *

Please share any other relevant information. *

*In case found COVID-19 positive you can take the prescribed medicine mentioned below:

Paracetamol
Zanamivir

COVID Tracing form

COVID Tracing form

COVID – 19 Pandemic

Lorem ipsum dolor sit amet, consectetur adipiscing elit quisque rutrum pellentesqu.

porto@portotheme.com

800-123-4567

Navigation

Extra Links

Subscribe to Newsletter:

This is custom heading element