Name *

First Name

Last Name

Temperature

I confirm that my temperature is lower than 37.5 C

Symptoms

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

Close Contact

I have not been in close contact with a COVID-19 patient in the last 14 days

Date

MM

DD

YYYY

Confirmation

I confirm that the information I have given is accurate and correct.