Do you currently have a cough?*
Do you have a fever now and/or have you had a fever in the past 14-21 days?*
Have you come in contact with any confirmed COVID-19 positive patients in the last 14 days?*
Are you experiencing shortness of breath or difficulty breathing?*
Are you experiencing other flu-like symptoms, such as gastrointestinal upset, headache, or fatigue?*
Have you experienced a recent loss of taste and/or smell?*
Have you traveled in the past 14 days to any other regions affected by COVID-19?*
I understand that I will be required to wear a mask to enter and while in PILI’s offices if I am not fully vaccinated.*
I will contact PILI ( before arriving at its offices if any of my answers to the above questions should change.*
Date of your expected visit to PILI’s offices:*
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