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Covid-19 Health Declaration

How are you feeling today?

First Name

Last Name

Email

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

Thanks for submitting!

Health Declaration

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

First Name

Last Name

Date of Birth

Email

If you answered yes to any question, please elaborate

Initials

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

Phone

Select an Address

Thanks for submitting!

hello@melbourneshiatsu.com.au

Melbourne Shiatsu

43 Rose St, Fitzroy VIC 3065, Australia

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