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Mandatory Child Health Check Form

Please select the location you want to visit *
Please select the child *

Does your child or anyone in your household have a fever, cough, sore throat, shortness of breath or a new loss of taste or smell?

Yes
No
Please select the child *

Does your child or anyone in your household have a fever, cough, sore throat, shortness of breath or a new loss of taste or smell?

Yes
No
Please select the child *

Does your child or anyone in your household have a fever, cough, sore throat, shortness of breath or a new loss of taste or smell?

Yes
No
Please select the child *

Does your child or anyone in your household have a fever, cough, sore throat, shortness of breath or a new loss of taste or smell?

Yes
No
Please select the child *

Does your child or anyone in your household have a fever, cough, sore throat, shortness of breath or a new loss of taste or smell?

Yes
No

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