Health Declaration Form

Health Declaration:
Please fill in the details and information below. This declaration must be filled out every time you want to enter Footsie premise.
Reminder:
You are requested to be honest and responsible for all information provided. Any fraudulent information, legal action will be taken.

Full Name

Identification/Passport No.

Mobile No.

Have you recently travelled overseas, during the past Fourteen (14) days?
YesNo

Have you been in contact with a confirmed/ suspected Covid-19 case in the past
YesNo

Do you have any of the following symptoms in the past fourteen (14) days? Fever, cough, runny nose, shortness of breath, headache, sore throat or diarrhea.
YesNo

BODY TEMPERATURE:

I, the undersigned hereby declare and confirm that I have not been exposed directly (or indirectly, to the best of my knowledge) to anyone with the risk of OR is positive for Covid-19. Also, I have not travelled to high risk areas/countries for the past fourteen (14) days.

I am also aware that despite Footsie Family Wellness and its subsidiaries having exercised and implemented full effort in cleaning and reducing the risk of Covid-19, due to the nature of the virus, I may have contacted the virus before, during and after the treatment(s) and will not hold FOOTSIE FAMILY WELLNESS liable for any health implications caused by the virus.

Upon signing of this form, I also hereby declare that all information disclosed by me are complete, true and accurate. I currently do not have any symptoms related to Covid-19 that may jeopardize FOOTSIE FAMILY WELLNESS businesses by exposing its patron(s) and employee(s) to the virus.

Health Declaration Form

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