Covid-19 Health Form | Uncommon Yarrow

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Covid-19 Health Declaration

How are you feeling today?

First Name

Last Name

Email

My body temperature is lower than 100.3°F/37.9 °C

I am not experiencing the following symptoms: fever, cough, sore throat, shortness of breath, diarrhea, loss of smell or taste

I haven’t been in close contact with a Covid-19 patient in the last 14 days

Initials

Date

I declare that the info I’ve provided is accurate & complete

Thanks for submitting!

Phone

971-285-6046

rebecca@uncommonyarrow.com

Address

1235 NW 19th Ave

Portland, OR 97209

Email

Connect

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