COVID-19 Exposure Agreement Form

Full Name

First NameLast Name

Email

example@example.com

Phone Number

Format: (000) 000-0000.

Do you have any of the following symptoms?:

Have you been in contact with anyone in the last 14 days who is experiencing these symptoms?

Have you been in contact with anyone who has since tested positive for Covid-19?

Have you travelled outside California in the last 1-2 months? Where did you go?

I hereby acknowledge the above symptoms and confirm that I, as well as all the members of my household, have not experienced any listed symptoms in within the last 30 days.

First NameLast Name

I confirm that I, as well as all members of my household, have not been diagnosed with COVID-19 within the last 30 days.

First NameLast Name

I confirm that I, as well as all members of my household, have not knowingly been exposed to anyone diagnosed with COVID-19 in the last 30 days.

First NameLast Name

I understand the potential health risks asociated with unintentional exposure to the COVID-19 virus. By signing below, I agree to release this facility and it's staff from all liability concerning any possible exposure and health risks associate with COVID-19 I may encounter due to my procedure.

Name

First NameLast Name

Signature

COVID-19 Screening Form