COVID-19 Protocols | piedmontpfha

Covid-19 Health Declaration

How are you feeling today?

First Name

Last Name

My body temperature is lower than 100.4°F/ 38°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

I hereby release and hold harmless Piedmont PFHA, its officers, directors and volunteers (the “Releasees”) from legal liability and any and all actions, suits, damages, claims or judgments for damages or expenses (including reasonable attorneys’ fees and costs), that may result from any personal injury, illness, disability, death, or loss or damage to person or property, or any other claim demand, action or right of actions of whatever kind or nature, either in law or in equity, whether related to COVID-19 or otherwise regardless of fault, whether arising from the negligence of the Releasees or otherwise, to the fullest extent permitted by law.

Signature I acknowledge that my electronic signature shall have the same validity, force and effect as if I affixed my signature by my own hand

Date

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

Thanks for submitting!