New Applicant Corona Virus Exposure Acknowledgement

By entering your personal information and checking the box below you electronically acknowledge that you Certify the following set forth by promise senior solutions, lLC.

Applicant Name

First Name

Last Name

Last Four of Social Security Number

I Certify

I have not traveled outside the US in the past 3 months, and I have not had direct contact with any individual who has traveled outside the US in the past 3 months.

I Certify

I have not had exposure to patients or individuals that have tested positive for Covid-19 or had any symptoms associated with Covid-19.

I Certify

I am not currently presenting with any symptoms associated with Covid-19. Such as - Persistent Cough, Fever, Tightness of Chest, or Shortness of Breath.