Covid-19 Screening Survey | Preciousflower

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Covid-19 Health Declaration

How are you feeling today?

First Name

Last Name

Email

My body temperature is lower than 100.5°F/ 38°C

I am not experiencing the symptoms: fever, cough, sore throat

I haven’t been in close contact with a Covid-19 patient in the last 14 days

Initials

Date

I declare that the info I’ve provided is accurate & complete

Thanks for submitting!

289-304-7555/

365 777-2042

MONDAY TO FRIDAY - 9:00 AM - 4:00 PM

SATURDAY - 10:00 AM - 4:00 PM

SUNDAY - CLOSED

RESPITE CARE AVAILABLE 24/7

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