Authentication Verification 05/27/2020 15:10:44
| Have you or anyone in your household experienced any of the following symptoms in the past 2 weeks (Fever 100.4 degrees F+, cough, shortness of breath or other symptoms associated with COVID-19)? | Yes No
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| Have you been advised by a doctor, healthcare provider, or any public health authority to stay home or otherwise avoid contact with others? | Yes No
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| Have you recently been in contact with anyone who has tested positive for COVID-19? | Yes No
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| In the past 14 days, have you traveled to a restricted area that is under a Level 2, 3, or 4 Travel Advisory according to the U.S. State Department (including China, Italy, Iran, and most countries in Europe)? | Yes No
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| In the past 14 days, have you traveled to any states outside of Wyoming? | Yes No
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| If the previous answer is Yes, list the states you visited. |
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| My appointment is with the following employee(s) |
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| Authentication token |
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