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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 degrees Fahrenheit

I am not experiencing any known symptoms of Covid-19, including: fever or chills, cough, shortness of breath, fatigue, headache, body aches, new loss of taste or smell or sore throat

I haven’t been in close physical contact (6 feet or closer for a cumulative total of 15 minutes) with anyone who has tested positive for Covid-19 or anyone who has known symptons of Covid-19 in the last 14 days

Initials

Date

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

Thanks for submitting!

55 hilton avenue, suite 250

garden city, new york 11530

telephone 516.307.1350

facsimile 516.307-1351

please send all correspondence to:

734 Franklin Avenue, #750

garden city, new york 11530

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The information provided herein is not intended as a substitute for and does not constitute legal advice.

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