Wellness Center – Gun Lake Tribe Forms

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Name*

First Last

Phone*

Where can you be reached right now?

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County of Residence*

If you live out-of-state, please choose “other” at the bottom of the list.

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Other County of Residence*

What is the county and state where you reside?

Affiliation*

Check all that apply

Today's Activity*

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Do you have any of the following symptoms? Do not check if symptom is something you normally deal with.

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Symptoms*

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What is your temperature?*

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Contact*

Have you had any close contact with a person who is known or suspected to have COVID-19 in the last 14 days?

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Vaccination*

Have you received 2 doses of the Moderna or Pfizer Covid-19 Vaccine or 1 dose of the Johnson and Johnson COVID-19 Vaccine more than 14 days ago?

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Travel*

Have you traveled internationally or domestically in the last 14 days via mass transit including airplane, train or bus?

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Vaccination*

Have you received 2 doses of the Moderna or Pfizer Covid-19 Vaccine or 1 dose of the Johnson and Johnson COVID-19 Vaccine more than 14 days ago?