COVID-19 screening

COVID - 19

Testing, exposure and risk.
Have you been in contact with anyone with confirmed COVID 19 in the last 10 days?

YesNo
If YES, please provide date of contact.
If you have answered YES to the above question your appointment may be cancelled and rebooked. We will contact you if we need further clarification.
Have you had covid in the last 2 weeks?

YesNo
Is it 10 days since your FIRST positive test?

YesNo
Do you understand that, even with our cleaning, screening and PPE measures in place, there is still a risk of transmission of COVID-19 from attending the clinic?

Yes, I understandNo

Do you agree to inform us immediately should you develop any of the above mentioned symptoms OR should your general health change?

I agreeI disagree
Signature

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Thank you for taking the time to fill in this form. Click the submit button below and we look forward to seeing you at your appointment.

Take care

The OHC
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