Eat in form Covid time — Northeast Kitchen

Eat in form

According to new RIVM rules, we kindly ask you to provide following information. We will keep this form for 14 days. And this form will not be use as marketing purpose.

Name

First Name

Last Name

Phone

Do you (or the person for whom you are completing this form) currently have symptoms of, or have you been diagnosed with, pneumonia or coronavirus disease (COVID-19)?

In the past 14 days, have you (or the person for whom you are completing this form) been in contact with someone who is or could be infected with coronavirus?