Self Certification Form

Face-To-Face Appointment Requirements

If you meet the following self-certification criteria, we may be able help with a face-to-face visit during Alert level 3.

If you answer YES to any questions, please provide further details in spaces provided.

Question Title

* 1. Please enter your full name and contact number

Question Title

* 2. In the past 14 days you have had contact with a COVID-19 case or, have you visited a current location of interest or do you meet the higher index for suspicion criteria?

Yes

Question Title

* 3. Have you had any of the following symptoms in the past 14 days?
- Cough
- Fever
- Nausea
- Sneeze
- Sore throat
- Runny nose
- Shortness of breath
- Loss of sense of smell or altered sense of taste

Yes

Please print form and sign below to self-certify that the above information is true. If you do not have a printer, we will have you sign below upon entry.

Sign Here: __________________________________________________

Thank you. We will be in contact with you shortly.

Self Certification Form

Face-To-Face Appointment Requirements

Question Title

* 1. Please enter your full name and contact number

Question Title

* 2. In the past 14 days you have had contact with a COVID-19 case or, have you visited a current location of interest or do you meet the higher index for suspicion criteria?

Question Title

* 3. Have you had any of the following symptoms in the past 14 days?- Cough - Fever - Nausea- Sneeze - Sore throat - Runny nose - Shortness of breath - Loss of sense of smell or altered sense of taste

* 3. Have you had any of the following symptoms in the past 14 days?
- Cough
- Fever
- Nausea
- Sneeze
- Sore throat
- Runny nose
- Shortness of breath
- Loss of sense of smell or altered sense of taste