Health Declaration Form
Name
*
Mobile Number
*
Date
*
DD slash MM slash YYYY
Company
*
1) Do you have any of the following symptoms?
a) Fever
*
Yes
No
b) Sore throat
*
Yes
No
c) Cough
*
Yes
No
d) Breathlessness
*
Yes
No
2) Have you travelled outside India in last 2 months?
*
Yes
No
3) Have you been in contact with a person who has travelled outside India in the past 2 months?
*
Yes
No
4) Have you been in contact with a COVID-19 positive patient?
*
Yes
No
Schedule Site Visit
Name
*
First
Email
*
Phone
*
Date
*
MM slash DD slash YYYY
Time
9AM
10AM
11AM
12AM
1PM
2PM
3PM
4PM
5PM
6PM
7PM
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*
Email
*
Mobile Number
*
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