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Comprehensive Pediatric Urgent & Primary Care in Estero, FL.
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Health Declaration Form
Health Declaration Form
Please complete this form to ensure the safety and well-being of all participants. Submissions are valid up to 24 hours before the scheduled activity.
Is your body temperature below 98.6°F (37.5°C)?
Yes
No
Have you experienced a cough or sore throat in the past 48 hours?
Yes
No
Have you had shortness of breath or difficulty breathing in the past 48 hours?
Yes
No
Have you lost your sense of taste or smell in the past 48 hours?
Yes
No
Have you experienced unexplained fatigue, muscle aches, or a headache in the past 48 hours?
Yes
No
Have you been diagnosed with any contagious illness in the last 14 days?
Yes
No
Have you been in close contact with anyone confirmed to have a contagious illness in the past 14 days?
Yes
No
Do you have any medical conditions or allergies we should be aware of?
Yes
No
I confirm that the information provided is accurate to the best of my knowledge. I understand that providing false information may impact my participation. I agree to follow all safety guidelines set by the organizers.
Yes
No
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