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Covid-19 Health Declaration

How are you feeling today?

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Last Name

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I have checked the exposure site list and am not expected to be isolating or getting a covid test. Exposure sites can be found at https://www.dhhs.vic.gov.au/case-locations-and-outbreaks-covid-19

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 7 days

Date

I declare that the info I’ve provided is accurate & complete

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Health Declaration

Please fill out the following form
in order to participate in our activity.

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Last Name

Date of Birth

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If you answered yes to any question, please elaborate

Initials

I declare that the info I’ve provided is accurate & complete

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Thanks for submitting!

hello@melbourneshiatsu.com.au

Melbourne Shiatsu

43 Rose St, Fitzroy VIC 3065, Australia

ABN 82103408783.
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