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Covid-19 Health Declaration

How are you feeling today?

First Name

Last Name

Email

My body temperature is lower than 100°F

I have NOT had any of the following symptoms: temperature in the last 24-hours, cough, congestion, runny nose, shortness of breath or difficulty breathing, vomiting, nausea, diarrhea, chills, repeated shaking with chills, muscle pain, fatigue, headache, sore throat, loss of taste or smell.

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

OR

I DO have two or more symptoms and I will contact my healthcare provider right away and postpone entry to the facility.

Initials

Date

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

Thanks for submitting!

© 2024 by Skyline Center, Inc.

Corporate Compliance

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