Covid 19 Health Declaration

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First Name

Last Name

Email

I have not been in close contact with anyone that has travelled overseas in the last 14 days

I am not experiencing the symptoms: fever, cough, sore throat

I have not been in close contact with a Covid-19 patient in the last 14 days

I am not waiting on any Covid-19 test results

Initials

Date

I declare that the info I’ve provided is accurate & complete to the best of my ability

Thanks for submitting!

Elaine Lewis

And Breathe Counselling

30 Balmoral Rd

Epsom

Auckland

FB: @andbreathenz

P: (64+) 027 261 6699