COVID 19 DECLARATION | Rising Care Ltd Copy

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135 Stoke Quay, Ipswich, IP2 8SN

Email: rising carelimited@gmail.com

24/7 Hotline:07809293582

Office landline 01473604976

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Woman Getting Tested

Covid-19 Health Declaration

How are you feeling today?

First Name

Last Name

Email

My body temperature is lower than 98.6°F/ 37.5°C

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 14 days

Initials

Date

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

Thanks for submitting!

135 Stoke Quay

Ipswich

IP2 8SN

24/7 Hotline:07809293582

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