Health Screening Waiver - Auto Approval Decline

Health Screening Waiver
Status
Name

First NameLast Name
Email
example@example.com
Your Organization
Name of Person(s) You are Visiting
Date of Visit

MonthDayYear
Date
Have you experienced any of the following symptoms within the past 24 hours?*

NoYes
- Fever >100.4 degrees F or chills
- Cough and/or sore throat
- Shortness of breath or difficulty breathing
- Fatigue
- Loss of taste or smell
- Muscle or body aches
- Congestion or runny nose
- Nausea or vomiting or diarrhea
Within the past 14 days have you had close contact with or cared for someone who has been diagnosed with COVID-19 or suspected to have COVID-19?*

NoYes
Have been diagnosed with COVID-19 and not yet cleared to discontinue isolation?*

NoYes
Are under evaluation for COVID-19 (for example, waiting for the results of a viral test to confirm infection)?*

NoYes
I understand that my submission of this Health Screening Waiver stands as proof that I assume all risks of injury and illness associated with visiting {organization}. In addition, I understand viral infections, bacterial infections and other communicable diseases and illnessess my be present . There is a inherent risk of exposure to COVID-19 during your visit as it there is in the community. By submitting this survey, I assume all risks related to exposure to COVID-19 and {organization} disclaims any and all liability related thereto. Facemasks are mandatory in the facility at all times. If you feel unsafe at anytime, please leave the facility and reschedule another visit.
Organization
Should be Empty: