Covid 19 Health Declaration | NaturalCareMD

top of page

Ph: 214-383-4400
Fax: 214-383-4403

Home
Portal Registration
About Us
Primary Care Services
Patient Education
Functional Medicine
Patient Forms
Shop
Blog
Contact
Members Area
More

Use tab to navigate through the menu items.

NSMD%20Logo%20-%20Sanjay_edited.png

Covid-19 Health Declaration

How are you feeling today?

First Name

Last Name

Email

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

Parent/Guardian Name

Date

I declare that the info I’ve provided is accurate & complete

Thanks for submitting!

Subscribe Form

©2019 by Natural Care MD. All Rights Reserved.

bottom of page