Contact Tracing

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Let us do this part

Today's Date:

Sat Mar 7 2026 03:42

Practitioner:*

Please read and answer

Name*

Temperature *

Have you been in contact with anyone showing signs of Covid-19?*

Are you feeling under the weather?*

Where did you come from?*

If any provision, section, subsection, clause or phrase of this release is found to be unenforceable or invalid, that portion shall be severed from this contract. The remainder of this contract will then be construed as though the unenforceable portion had never been contained in this document.

Client Information

I hereby declare that I am of legal age (with valid proof of age) and am competent to sign this Agreement.

Name:

Address:

Postcode:

Date of birth:*

Age:

Phone #:

Email:

Signature:*

Sign or type signature: