Covid Health Declaration | littlestages

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Covid-19 Health Consent

How are you feeling today?

First Name

Last Name

Email

Current Temperature

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

Thanks for submitting!

Contact

info@littlestages.com

(973) 762-2679

Address

14 South Orange Avenue

South Orange, NJ 07079

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