Free Health Declaration Form Template
Health Declaration Form
Please complete this form to declare your current health status for safety and screening purposes.
Patient Information
Name
Date of Birth
Phone Number
Please provide your email address.
Health Status
Current Symptoms
Check all that apply.
Recent Exposure
Have you been in close contact with a confirmed COVID-19 case in the last 14 days?
Have you recently traveled outside the country?
If yes, specify location.
Vaccination Status
Are you fully vaccinated?
Date of Last Dose (if applicable)
Declaration
-
I declare that the information provided is true and complete to the best of my knowledge.
Signature
Name:
Date:
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