COVID-19 Customer Consent Form
Please read and agree to the following terms before proceeding.
Full Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date & Time of Visit
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please check the boxes to confirm the following:
*
I have not tested positive for COVID-19 in the past 14 days.
I have not experienced any COVID-19 symptoms in the past 14 days.
I have not been in close contact with anyone who has tested positive for COVID-19 in the past 14 days.
I agree to wear a face mask and practice social distancing during my visit.
Signature
Submit
Should be Empty: