Covid-19 Form | The Recovery Hub

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Covid-19 Health Declaration

How are you feeling today?

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Last Name

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My body temperature is lower than 98.6°F/ 37.5°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!

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Last Name

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Subject

Message

Thanks for submitting!

The Junction Sports & Leisure Centre,

Station Approach,

Broadstone,

Poole,

Dorset,

BH18 8AX

Tel: 07544 281 283

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