Declaración de salud | Clinica de especialidades médicas y dentales

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Declaration of health of Covid-19 Clinic of medical and dental specialties

How do you feel today?

Name

Surname

E-mail

My body temperature is less than 98.6 °F/ 37.5 °C

I am not experiencing any of these symptoms: fever, cough, sore throat

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

Initials

Date

I declare that the information I have provided is accurate and complete

Thank you for your message!

NAME

SURNAME

TELEPHONE

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