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Healing Body Well

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Health Declaration

How are you feeling today?

First Name

Last Name

Phone

Email

My body temperature is lower than 99.9°F

I am not experiencing the symptoms: fever, cough, sore throat, shortness of breath, fatigue, new loss of taste or smell, sore throat, non-allergy congestion or runny nose, nausea, vomiting, diarrhea, or new skin sores or rash.

I haven’t been in close contact with a person with Covid-19 or Monkey Pox in the last 14 days.

Initials

Date

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

Thanks for submitting!

© 2021 by Ama Dawn Greenrose.

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