Covid 19 Form | amberjeanphotos

How are you feeling today?

First Name

Last Name

Email

My body temperature is lower than 100.4°F/ 38.00°C

I am not experiencing the symptoms: fever, cough, sore throat

I haven’t been in close contact with a Covid-19 patient in the last 14 days

Initials

Date

I declare that the info I’ve provided is accurate & complete

Thanks for submitting!