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Covid-19 Health Statement
How do you feel today?
First Name
Last Name
Email
My body temperature is below 98.6 ° F / 37.5 ° C
I am not experiencing any of these symptoms: fever, cough, sore throat
I have not been in close contact with a Covid-19 patient in the last 14 days
Initials
Date
I declare that the information I have provided is accurate and complete
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Thanks for the survey
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