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COVID 19 Screening

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COVID-19 Screening
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  • If the answer to the last question was "yes" please state where you traveled:

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  • I hereby acknowledge the above information is truthful and correct, and I confirm that I, as well as all members of my household, have not experienced any listed symptoms related to Covid-19 within the last 30 days.

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  • I confirm that I, as well as all members of my household, have not been diagnosed with Covid-19 within the last 30 days. 

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  • I confirm that I, as well as all members of my household, have not knowingly been exposed to anyone diagnosed with Covid-19 in the last 30 days.

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  • I understand the potential health risks associated with unintentional exposure to the Covid-19 virus.  By submitting my name below, I agree to release this facility and its staff from all liability concerning any possible exposure and health risks associated with Covid-19, as it relates to myself and my child. 

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