COVID-19 WELLNESS FORM – MOBILITYSALON.COM COVID-19 WELLNESS FORM - MobilitySalon.com This online form MUST be completed and submitted within 24 hours prior to your appointment time, but no later than the night before your appointment. Name* First Last Email Address* Phone*Appointment Date* Date Format: MM slash DD slash YYYY You should be submitting this form within 24 hours prior to your appointment.Appointment Time* : HH MM AM PM You should be submitting this form within 24 hours prior to your appointment.Do you have a cough?*YesNoDo you have a fever now, or have you had a fever in the past 14 days?*YesNoHave you come in contact with any confirmed COVID-19 positive patients within the last 14 days?*YesNoAre you experiencing unusual shortness of breath or difficulty breathing?*(This is not referring to normal conditions such as asthma.)YesNoAre you experiencing other flu-like symptoms?*YesNoHave you experienced recent loss of taste or smell?*YesNoDo you have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?*YesNoHave you traveled into New York State from one of the following States within the past 14 days? If yes, please select the State.*NOAlabamaArkansasCaliforniaFloridaGeorgiaGuamHawaiiIowaIdahoIllinoisIndianaKansasKentuckyLouisianaMinnesotaMissouriMississippiNorth CarolinaNorth DakotaNebraskaNevadaOklahomaPuerto RicoSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVirgin IslandsWisconsinCommentsThis field is for validation purposes and should be left unchanged.