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REPORTE DE SALUD - CIRCULACION A ZONAS COVID-19
El presente Formulario Tiene caracter de Declaración Jurada
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APELLIDO
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NOMBRE
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DNI
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LOCALIDAD DE RESIDENCIA
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Choose
CARHUE
E.A GASCON
LEUBUCO
RIVERA
SAN MIGUEL A.
VILLA MAZA
CALLE
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NUMERO
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TELEFONO DE CONTACTO
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EMPRESA
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MOMENTO DEL REGISTRO
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MM
/
DD
/
YYYY
Time
:
AM
PM
TEMPERATURA
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Your answer
SENTIS DOLOR DE GARGANTA?
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SI
NO
SENTIS FALTA DE AIRE?
*
SI
NO
PERDISTE EL SENTIDO DEL GUSTO U OLFATO?
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SI
NO
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