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Covid 19 Disclaimer -Form Fill

Section One
Q1

Name

First Name
Q2

Name

Last Name
Q3

Phone Number

Phone Number
Q4

Address

Street Address
Q5

Address

Street Address Line 2
Q6

Address

City
Q7

Address

State / Province
Q8

Address

Postal / Zip Code
Q9

Are you experiencing a cough?
Q10

Are you experiencing shortness of breath?
Q11

Have you had a fever (above 37.7C degrees) in the last 14 days?
Q12

Have you noticed a loss or change in your sense of taste or smell?
Q13

Have you had any contact with anyone that has suspected COVID-19 in the last 14 days?
Q14

Client Signature
Q15

Date

Date