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P: (401) 780-8769

Covid-19 Health Declaration

How are you feeling today?

First Name

Last Name

Phone number

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

Membership ID #

Date

Your Member ID # is your last initial followed my the last 4 digits of your drivers license or State ID card

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

We accept all major credit & debit cards plus now accept contactless payments

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