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2940 Highway Ave, Highland, IN 46322

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Covid-19 Screening

Please complete ONLY within 24 hours of your next appointment.

First Name

Last Name

Email

My body temperature is lower than 98.6°F/ 37.5°C

I am not experiencing the symptoms: fever, cough, sore throat

I haven’t been in close contact with a Covid-19 patient in the last 14 days

Appointment Date

Date

I declare that the info I’ve provided is accurate & complete

Thanks for submitting your Covid screening form!

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