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Covid-19 Health Declaration
First Name
Last Name
Email
I am experiencing the following symptoms which are new or worsened if associated with allergies, chronic or pre-existing conditions; fever, cough shortness of breath, difficulty breathing, sore throat, and/or runny nose, headache, muscle/joint pain, fatigue/severe exhaustion, chills
I have returned or been in close contact with someone who has returned to Canada from outside the country in the past 14 days
In the past 14 days, I have been notified by AHS, employer, social event you attended that you were connected to an outbreak or are a close contact of a person who has a confirmed case of COVID-19 or an acute respiratory illness
Initials
Date
I can provide proof of having two COVID-19 vaccinations, documentation of a medical exemption or proof of a privately-paid negative PCR or rapid test within 72 hours of service (tests from AHS or Alberta Precision Laboratories not allowed)
I declare that the info I’ve provided is accurate & complete
Submit
Thanks for submitting!
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