covid screaning questionair

Covid-19 Health Declaration

How is everyone feeling?

First Name

Last Name

Email

Temperature lower than 98.6°F/ 37.5°C

Not experiencing any of the following symptoms: fever, cough, sore throat, head

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!

Tel 347-898-4000