CherryHill Site Check In

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Location*

Name

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Phone

Reason for Visit*

Health Declaration - Part 1*

Agree

BY AGREEING TO THIS HEALTH DECLARATION, YOU ARE CONFIRMING THAT YOU DO NOT PRESENT WITH ANY OF THE BELOW SYMPTOMS: Fever • Cough • Shortness of breath

Health Declaration - Part 2*

Agreed

BY AGREEING TO THIS HEALTH DECLARATION, YOU ARE CONFIRMING THAT YOU HAVE NOT: Recently been in contact with someone diagnosed with Coronavirus to your knowledge, and have not traveled outside Australia in the last 2 weeks.