COVID-19 Assessment Form

Covid-19 Health Declaration

How are you feeling today?

First Name

Last Name

Email

I am aware that I must wear a mask during the duration of my visit and that a non contact body temperature reading may be taken.

I am not experiencing the symptoms: fever, cough, sore throat, lost sense of taste, runny nose, shortness 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!