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Covid-19 Health Declaration

How are you feeling today?

First Name

Last Name

Email

My body temperature is lower than 98.6°F/ 37.5°C

I am NOT experiencing COVID-19 symptoms: fever, cough, loss of smell, change in taste etc.

I have NOT been in close contact with a Covid-19 patient in the last 14 days

I have NOT been diagnosed with Covid-19 in the past 14 days

Signed (Initial)

Date

I declare that the information I have provided is accurate and I am aware I will be required to rearrange my appointment if I am unable to complete the above declaration.

Thanks for submitting!

* This form is only valid for up to 48hours before your appointment.

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