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Flint Region

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Covid-19 Health Declaration

Please complete this form NO MORE than 24 Hours prior to your appointment

First Name

Last Name

Email

Phone

My body temperature is lower than 99.1 degrees Farenheit

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

I have not traveled outside the state of Michigan in the last 2 weeks

Initials

Date

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

Thanks for submitting!

Hours of Operation

Mon:

Tue:

Wed:

Thur:

Fri:

Sat:

Sun:

8am - 4:30pm

8am - 4:30pm

7am - 4:30pm

8am - 4:30pm

8am - 4:30pm

Closed

Closed

Contact us

2300 Austins Pwky

Flint, MI 48507

Phone: 810-893-6950

Fax: 810-820-6841

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