Covid 19 - Health check

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Breathe Salt Wellness- Health Screening and Cohort Agreement

FIRST and LAST NAME *

Have you had a fever in last 48 hours? *

Yes

Are you being currently tested for Covid 19? *

Yes

Have you been traveling outside of British Columbia in last 14 days? *

Yes

Have you been exposed to a person that was diagnosed for Covid 19 or is being tested for Covid 19 in last 14 days? *

Yes

Are you coming with another person today for a session that is in your Cohort /Core Bubble group ?(Do you agree and comply with Province-wide restriction requirements that the additional person is your family member or person in care that you live with or care for?) *

Yes

Coming alone

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms