Health Declaration Form

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

        Email

        Please provide your email address.

          Health Status

          Current Symptoms

          Check all that apply.

            FeverCoughSore ThroatShortness of BreathLoss of Taste/SmellBody AchesNone of the Above

            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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