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Mount Ommaney & North Ipswich

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

Initials

Date

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

Thanks for submitting!

0409367716

Shop 2/9 Pine Mountain Road,

North Ipswich QLD 4305,

Mount Ommaney Shopping Centre

Opposite Westpac Bank

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