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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 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!

Form 1 of 3

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

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