Covid Tracing | Cohost

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COVID-19

Contact Tracing Form

First Name

Last Name

Email

Phone

Do you currently have, or have you had any of the following conditions?

Cough

Fever

Shortness of Breath

Chills

Headache

Sore Throat

Muscle Pain

New Loss of Taste or Smell

None of the Above

Do you have knowledge of, or have you had close contact in the past 14 days with person who has been diagnosed with COVID-19?

Yes

No

Have you been in an area with known risk of, reported cases of COVID-19, or travelled by public transportation (bus, train, plane, etc.) within the past 14 days?

Yes

No

I hereby certify to the best of my ability and knowledge to inform of any changes in the above information, and that I have read and agree that the information I have provided is complete and true to the best of my knowledge. (By checking this box I understand and accept this statement)

During this COVID-19 pandemic, I understand I may get an infection at Cohost. I hereby agree to not sue and to waive all liabilities towards Cohost for anything that happens during or after my visit. (By checking this box I understand and accept this statement)

today's date

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COVID-19

Contact Tracing Form

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8712 271st St, Stanwood, WA 98292 | hello@cohostspace.com | Tel. 360-572-3352

8712 271st St, Stanwood, WA 98292 | | Tel. 360-572-3352