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GHOSTWOLFE HOLDINGS

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Covid-19 Questionnaire

Please fill out the following form to help us understand your health condition.

First Name

Email Address

Last Name

Date of Birth

Have you been exposed to anyone with Covid-19? Or, have you traveled outside the U.S. within the past 90 days? *

No

Yes

Have you been treated for Covid-19 in the past 90 days? *

No

Yes

If you answered yes to any question, please elaborate

Initials

Today's Date

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

We Appreciate Your Submission!

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