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COVID & General Health Symptoms Declaration
This form is to verify that you are in compliance with the health declarations as described below.
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* Indicates required question
Email
*
Your email address
First Name?
*
Your answer
Last Name?
*
Your answer
Phone Number? (area code first)
*
Your answer
zip code?
*
Your answer
My body temperature is lower than 100 degrees Fahrenheit.
*
Yes
No
Not Sure
I am not experiencing any symptoms: loss of smell fever, incessant cough or sneeze, sore throat, chills, intense head ache, body aches, nausea, diarrhea.
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Yes - having no symptoms
No - having symptoms (1 or all of the following symptoms)
I have not been in close contact with a COVID infected person in the last 14 days.
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Yes -I have not been in contact
No - I have been in contact
I have not tested positive for COVID in the the last 30 days?
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Yes -I have not tested positive
No - I have tested positive
I have not traveled outside of the country in the last 30 days?
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Yes -I have not traveled out of the country
No - I have traveled outside of the country
I affirm that the information on this form is accurate and true to the best of my knowledge.
*
I affirm
I do not affirm
Other:
Required
Please include initials.
*
Your answer
Send me a copy of my responses.
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