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Covid-19 Health Declaration

Please complete this form before the scheduled appointment

First Name

Last Name

Email

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

I am not experiencing any of the following symptoms: fever, continious dry cough, loss of smell or taste

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

Initials

Date

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

Thanks for submitting!

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