Cleaning Services Health Declaration Form

To further safeguard everyone involved, we require all clients to complete this Health Declaration Form before availing of our cleaning services. Your cooperation in providing accurate information is essential in maintaining a safe environment for everyone.

Personal Information

Full Name:
Date of Birth:
Address:
Phone Number:
Email Address:

Health Declaration

Please answer the following questions honestly:

1. Have you or anyone in your household experienced any illness or symptoms in the past 14 days that may be contagious?

   • Yes

   • No

2. Have you or anyone in your household been diagnosed with any contagious illness or condition in the past 14 days?

   • Yes

   • No

3. Have you or anyone in your household been in close contact with someone who has a contagious illness or condition in the past 14 days?

   • Yes

   • No

4. Have you or anyone in your household traveled internationally in the past 14 days?

   • Yes

   • No

5. Do you currently have any health conditions or concerns that may affect your ability to safely participate in cleaning activities?

   • Yes

   • No

6. Have you experienced any recent injuries or surgeries that may limit your ability to perform cleaning tasks?

   • Yes

   • No

7. Are you allergic to any cleaning products or materials commonly used in cleaning services?

   • Yes

   • No

8. Do you have any physical limitations or disabilities that may require accommodation during cleaning services?

   • Yes

   • No

Declaration

I hereby declare that the information provided above is true and accurate to the best of my knowledge. I understand that providing false information may put others at risk and may result in the cancellation of cleaning services.

Signature:

Date:                               

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