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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
Submit
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