COVID-19 Precaution Form
Temperature Check
Done upon arrival
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Have you returned from travel including travel within the UK, U.S.A or Canada in the last 14 days?
Yes
No
Have you had exposure to a confirmed positive case of COVID-19?
Yes
No
Do you have any of these symptoms that are not caused by another condition:
Cough
Fever
Chills
Shortness of breath or difficulty breathing
Fatigue
Muscle or body aches
Headache
Sore throat
Recent loss of taste or smell
Diarrhea
Nausea or vomiting
Have you had a positive COVID-19 test in the past 10 days?
Yes
No
By submitting this form, I agree with the following statement:
All the information provided here true and accurate.
Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature
Submit
Should be Empty: