COVID-19 Self-Declaration-Form

Please correct the errors described below.

The self-declaration form is required in order to screen and safeguard the health and safety of Appleby Foot Care & Orthotics employees and patients.

hereby certify, represent and warrant as follows: Within the last twenty-one (21) days, I HAVE NOT:
  • tested positive or presumptively positive with the COVID-19 or been identified as a potential carrier of the COVID-19 virus or similar communicable illness ("Coronavirus")
  • experienced any symptoms commonly associated with the Coronavirus that includes.
  • severe difficulty breathing
  • severe chest pain
  • recent Los of consciousness
  • fever
  • new cough
  • sore throat
  • new severe headaches, diarrhea, stomach ache
  • muscle aches
  • Fatigue
  • been in any location positively designated as hazardous and/or potentially infected with the COVID-19 by a recognized health or regulatory authority, such as a country for which the Government issued a Travel Advisory for COVID-19
  • been in direct contact with or the immediate vicinity of any person I knew and/or now know to be carrying the COVID-19 or has been identified as a potential carrier of the COVID-19.

Do any of the following apply to you?

  • Above the age of 65
  • Conditions affecting the immune system such as auto-immune disease, HIV etc.
  • A chronic health condition such as diabetes, COPD etc.
  • Any treatment affecting immune system such as corticosteroids, chemotherapy etc

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Thank you for this information and helping us prevent the spread.

Your information will be encrypted.