Covid-19 Form

Covid-19 Health Declaration

Name(Required)

First Last

Email(Required)

My temperature(Required)

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

Covid-19 Symptoms(Required)

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

Contact(Required)

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

Initials(Required)

E.g. JD

Date

Declaration(Required)

I declare that the information I have provided is accurate and complete.

CAPTCHA