iconfirm.health

Confirmation has been sent to SomeCompany Inc
Please download the confirmation PDF & bring to the meeting.

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Complete form below

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 Name: Email: Password: Age: Under 18 18 or older

2Your health

Are you experiencing any of the following:

Difficulty breathing Chest pain Feeling confused Body temperature over 37.5 °C / 99.5 °F Sore throat Runny nose

In the past 10 days, have you experienced any of the following:

Fever Cough or worsening of chronic cough

In the past 10 days, have you had close contact with someone who is confirmed as having C0V1D-I9?

No Yes

3Confirmation

Choose ID: ID Not Required

More Info (optional):

Is the information provided accurate? Yes No

Signature here Clear

?download="proposed_file_name"

All personal information is encrypted & not passed to SomeCompany Inc or third parties.
SomeCompany Inc. will recieve notification you confirmed.
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