Home COVID‐19 PANDEMIC ‐ PATIENT DISCLOSURES FORM COVID‐19 PANDEMIC ‐ PATIENT DISCLOSURES FORM "*" indicates required fields First Name* Last Name* Email* Do you have any COVID related symptoms? (Including fever, shortness of breath, dry cough, loss of sense of taste or smell)* Yes No Have you been in close contact with someone who has tested positive for COVID?* Yes No Are you or someone in your household awaiting a COVID test result?* Yes No Date* MM slash DD slash YYYY