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Formulario sin título
Declaración jurada por COVID-19
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* Indicates required question
Apellido y nombre
*
Your answer
Turno
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Mañamna
Tarde
Documento
*
Your answer
Edad
*
Your answer
Domicilio
*
Your answer
Celular
*
Your answer
Fiebre
*
SI
No
Tos
*
SI
NO
Dolor de garganta
*
SI
NO
Falta de aire
*
SI
NO
Diarrea/dolor abdominal
*
SI
NO
Malestar general
*
SI
NO
Perdida de olfato
*
SI
No
Otros síntomas
*
Your answer
Contacto estrecho con positivo de COVID-19
*
SI
NO
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