Name *

First Name

Last Name

Contact Cell/Phone Number * *

(###)

###

####

I am aware that due to limited testing for the COVID-19, the virus has a long incubation period during which time carriers of the virus may be asymptomatic (no symptoms) and still be highly contagious. I also acknowledge that it is impossible to determine who has it . *

Yes, I am aware.

I also acknowledge that I understand that anytime I am within close proximity (less than 6ft) of my service provider or any other person, I could have an elevated risk of contracting the virus should it be present. *

Yes

I confirm that none of the following COVID-19 symptoms have been present within the last 2-14 days: Fever, Shortness of Breadth, Loss of taste or smell, Dry Cough, Runny Nose, Sore Throat, Chills, Repeated Shaking with Chills, Muscle Pain or Head Ache *

None of the Above

Other (Specify Below)

I affirm that I have not been exposed to anyone that has been diagnosed with COVID-19 within the past 14 days inside or outside of the country I reside in. *

I Confirm

Other ( Specify Below)

I affirm that I have not traveled domestically (outside of my state) or internationally (outside of my country) within the past 14 days. *

I Confirm

Other (Specify Below)

Do you suffer from allergies *

Yes, explain symptoms below

No

I agree by providing my name below, I am in essence rendering my signature in acknowledgement of the completed statements on this form and that all information is accurate as of the date of this form. *

First Name

Last Name