Telecommunications Store Health Screening Waiver Form
Please complete this health screening waiver before entering the telecommunications store. Your responses help us maintain a safe environment for all customers and staff.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Visit
*
-
Month
-
Day
Year
Date
Have you experienced any of the following symptoms in the last 14 days? (Fever, cough, shortness of breath, or sore throat)
*
No
Yes
Have you been in close contact with anyone diagnosed with a contagious illness in the last 14 days?
*
No
Yes
Are you currently awaiting results from a recent health screening or test for a contagious illness?
*
No
Yes
Store Location Visited
*
Please Select
Downtown Branch
Mall Kiosk
Suburban Outlet
Other
Waiver and Consent
*
By signing below, I confirm that the information provided is accurate and complete to the best of my knowledge. I understand this screening is for general safety purposes and does not constitute medical advice.
*
Submit Waiver
Submit Waiver
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