Health Declaration Form

Due to the close contact of the treatments provided, please ensure the information provided is accurate.

If your condition changes prior to your treatment, please Contact Us at reanimar.sm@gmail.com as soon as possible.

First Name

Last Name

I am not running a fever/high temperature and my body temperature is lower than 37.5°C

I am not experiencing any of the following symptoms: cough, sore throat, chills. shortness of breath, fatigue, muscle aches, headache, new loss of taste or smell, nausea, vomitting or diarrhea

To the best of my knowledge, neither I, nor anyone in my household has been in close contact with anyone who has tested positive for Covid 19 in the last 14 days

Initials

Date

I declare that the information I’ve provided is true and accurate

Thanks for submitting!