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The Chapel of the Incarnate Word

Covid-19 Health Declaration

This form must be filled in and submitted - on THE DAY OF YOUR VISIT - by anyone visiting the Chapel of the Incarnate Word, or the Heritage Center

First Name

Last Name

Email

Phone

My body temperture is normal; I am not experiencing fever, cough or sore throat; I have not been in contact with a COVID 19 patient in the last 14 days.

Where will you be?

Initials

Date

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

Thank you, and welcome.

The Chapel of the Incarnate Word

4503 Broadway

San Antonio, Texas 78209

210-828-2224, ext. 294

www.ccvichapel.org

© 2022 The Sisters of Charity of the Incarnate Word. All rights reserved.

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