Covid-19 Declaration

I declare that I do not have any of the following symptoms
- Fever(feeling hot to the touch, a temperature of 37.8 degrees Celsius or higher)
- Chills
- Cough that's new or worsening(continuous, more than usual)
- Barking cough, making a whistling noise when breathing(croup)
- Shortness of breath(out of breath, unable to breathe deeply)
- Sore throat
- Difficulty swallowing
- Runny nose(not related to seasonal allergies or other known causes or conditions)
- Stuffy or congested nose(not related to seasonal allergies or other known causes or conditions)
- Lost sense of taste or smell
- Pink eye(conjunctivitis)
- Headache
- Digestive issues(nausea/vomiting, diarrhea, stomach pain)
- Muscle aches
- Extreme tiredness that is unusual(fatigue, lack of energy)
- Falling down often
- For young children and infants: sluggishness or lack of appetite
Name
First Last
Signature
Date
MM slash DD slash YYYY

Please make sure to click on the submit button on this page, as well as on the patient registration form