Appointment Check-in and Coronavirus Self Declaration Form
For the health and safety of our community, declaration of illness is required. Be sure that the information you'll give is accurate and complete. Please get immediate medical attention if you have any of the COVID-19 signs.
Date of Birth:
Have you travelled abroad during 2020?
Name of the area(s) visited
Country, State, City
Dates of travel
Arrival and return dates for each area
Have you been in contact with people being infected, suspected or diagnosed with COVID-19?
Your relationship with the people and your last contact date with them
Please state whether you've experienced/are experiencing the following
Shortness of Breath
Persistent Pain in the Chest
I acknowledge that the information I've given is accurate and complete.
Should be Empty: