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HEALTH CHECK

Covid-19 Health Declaration

How are you feeling today?

First Name

Last Name

Email

I am not currently diagnosed or believe I have Covid-19

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

I am not experiencing the symptoms: fever, new or continuous cough, sore throat, loss or change to your sense of smell or taste, unexplained shortage of breath

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

Initials

Date

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

Thanks for submitting!