COVID-19 Form

Name *

First Name

Last Name

Do you have a fever or respiratory symptoms? Symptoms include fever OR a cough, sore throat, fatigue and shortness of breath with or without a fever. *

Yes

No

Not sure

Are you waiting for COVID-19 test results? *

Yes

No

Not sure

Have you been identified as a close contact of a confirmed case of Coronavirus? *

Yes

No

Not sure

Have you been asked to self-isolate by your doctor, another health professional or a government authority?

Yes

No

Not sure

Declaration *

The information I have provided in this questionnaire is true and correct.

I agree to follow 'COVID-Safe' procedures during my visit - including hand washing/santising, physical distancing, and mask use as required.

I agree to let you know if any of the details I have given change, particularly with regards to developing any symptoms of, or exposure to COVID-19.