Covid19 Form | Mysite

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Covid-19 Health Declaration

How are you feeling today?

First Name

Last Name

Email

My body temperature is lower than 98.6°F/ 37.5°C

I am not experiencing the symptoms: fever, cough, sore throat

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

Initials

Date

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

Thanks for submitting!

LOCATION & HOURS

Summit, New Jersey

Tues: 10am - 4pm

Wed: 10am - 8pm

Thurs: 10am - 8pm

Fri: 10am - 8pm

Sat: 9am - 4pm

Sun: 10am - 4pm

Closed Mon.

Enter Your Name

Enter Your Email

Enter Your Subject

Message

Thanks for submitting!