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C H I

NEW YORK

CARNEGIE

HILL

Outpatient

Substance Abuse & Chemical Dependency Treatment Center

INSTITUTE

Form 1 of 3

Covid-19 Health Declaration

How are you feeling today?

First/Nickname

Contact Number

Email (do not use this field if you email contains identifying information. This field is NOT required)

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

I understand that this form does not meet HIPPA requirements. By checking this box I affirm that I have not included any identifying information within the contents of this form.

Thanks for submitting!

Form 1 of 3

Carnegie Hill Institute |116 East 92nd Street |New York, NY 10128

OTP (212)-289-7166 | CDOP (646)-672-1105