Bank Health Declaration Form
Please complete the Bank Health Declaration Form before your visit or service request. This form helps us ensure a safe and comfortable environment for everyone.
Full Name
*
First Name
Last Name
Are you a staff member or a customer?
*
Staff
Customer
Contact Email
*
example@example.com
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Visit or Service
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Have you experienced any of the following symptoms in the past 14 days? (e.g., fever, cough, sore throat, shortness of breath)
*
Fever
Cough
Sore throat
Shortness of breath
None of the above
In the past 14 days, have you been in close contact with anyone who is unwell or has shown symptoms of illness?
*
Yes
No
Have you traveled internationally in the past 14 days?
*
Yes
No
Are you currently feeling well and able to attend your visit or service?
*
Yes
No
Signature
*
Submit Declaration
Submit Declaration
Should be Empty: