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COVID 19 Symptom Release

COVID 19 Symptom Release Form

PLEASE READ & COMPLETE THE FORM BELOW

Known symptoms of COVID19 are:

Fever above 100.4F

Excessive Fatigue

Dry Cough

Shortness of Breath

GI Tract Issues

Name

First Name

Last Name

I understand the above symptoms and affirm that I have not been in contact with anyone that is known to possibly have symptoms of COVID19, and also affirm that I have not currently experienced the symptoms listed above in the past 14 days.

I affirm that I have not knowingly been in contact with anyone that has tested positive for COVID19 and I have not been diagnosed with COVID19 within the past 30 days.