Holly Bell RMT

First and last name

Email address

Phone number

Have you or a member of your household been tested for Covid-19 in the past 21 days?

Yes
No

Do you currently have any of the following symptoms? Please check any or all that apply

Cough, shortness of breath
Fever, chills
Loss of taste or sense of smell

Have you received a Covid-19 vaccination or booster dose in the past 21 days?

Yes
No