COVID-19 Exposure Agreement Form

Full Name*

First NameLast Name

Email*

example@example.com

Phone Number*

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?*

YesNo

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

YesNoNot Sure

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