COVID-19 Entry Health Form
For Restaurant Patrons
Full Name
Phone Number
Email Address
Date of Visit
Have you experienced any of the following symptoms in the past 14 days?
Fever
Cough
Shortness of breath
Sore throat
None of the above
Have you been in close contact with anyone diagnosed with COVID-19 in the past 14 days?
Yes
No
Have you traveled internationally or to a high-risk area within the past 14 days?
Yes
No
I confirm that the above information is accurate.