Covid 19 | gallerysoview.com

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Health Declaration - COVID-19

We think about your health! Please fill out this Form !

Last Name

First Name

E-mail

My body temperature is below 37.5 ° C / 98.6 ° F

I don't have symptoms: fever, cough, sore throat

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

Please choose the time of your visit

Date of your visit

I declare that all the information I have provided is correct and complete

we have received your information. Thank you

For more informations on COVID 19

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