COVID-19 Health questionnaire

First Name

Last Name

Email Address

Phone

Are you currently required to be in isolation because you have been diagnosed with coronavirus (COVID-19)?

Yes

Have you been directed to a period of 14-day quarantine by the Department of Health and Human Services as a result of being a close contact of someone with coronavirus (COVID-19)?

Yes

Are you experiencing any of these symptoms; Fever, Chills, Cough, Sore Throat, Shortness of Breath, Runny Nose or Loss of Sense of Smell?

Yes

I declare that the information provided is accurate & complete

If you answered YES to any of the above questions you should not attend our office until advised by the Department of Health & Human Services that you are released from isolation or until a 14-day quarantine period is complete. If you answered NO you are welcome to attend the session, please wear a mask and social distance at all times.

Thanks for submitting, details will be deleted after 28 days