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Hello
To protect our customers & staff, before your meeting today at SomeCompany Inc, you are required to complete the following health self assesment.

 

?download="proposed_file_name"

Self Declaration

Today I confirm I am in good health & symptom free
1Your basic info
2Your health
Are you experiencing any of the following:
In the past 10 days, have you experienced any of the following:
In the past 10 days, have you had close contact with someone who is confirmed as having C0V1D-I9?
3Confirmation

Signature here Clear
?download="proposed_file_name"
Your signature will go here!

All personal information is encrypted & not passed to SomeCompany Inc or third parties.
SomeCompany Inc. will recieve notification you confirmed.
iconfirm.health terms & privacy agreements apply.