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Date of Birth

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How are you feeling today?

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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

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Office:

72205 Painters Path,

Palm Desert, CA, 92260

Contact :

Tel: 760-695-4202