Covid Questionnaire | Mysite

This site was designed with the

website builder. Create your website today.Start Now

Home
About
Menus
Menu
Contact
Covid Questionnaire
More

Use tab to navigate through the menu items.

Covid-19 Health Declaration

How are you feeling today?

First Name

Last Name

Phone

I am not sick with a cold/flu and am not displaying any signs of Covid-19 and/or flu-like symptoms

I have not returned from outside the country (including Canada/ USA) in the past 14 days

In the past 14 days, at work or elsewhere, I have not been in close contact with someone who has a probable or confirmed case of COVID-19

I have 2 Valid doses of Covid Vaccine

Approximate Time

Date

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

Thanks for submitting!

Hours: ***May be Temporarily changed due to Lockdown***

Mon: *CLOSED*

Tues-Thur: 4pm-9pm

Fri : 1pm-9pm

Sat & Sun: 4pm-9pm

© 2019 by Churchill Arms.

Proudly created with Wix.com