Covid Declaration Form

Declaration Form

Covid-19
Name

First Name Last Name
Mobile

Area code Phone Number
Date of Birth

Month Day Year
Date
Email
Do you have a cough, cold or any flu like symptoms, including sore throat, hay fever, sinusitis, a post nasal drip, body aches or fever

Yes No
Have you been overseas or in contact with anyone who has been overseas within the past 14 days prior to your appointment

Yes No
Have you been in contact with anyone who has flu like symptoms within the last 14 days

Yes No
I agree to a temperature check and to abide by all the health and hygiene protocols stipulated by Janine Gaddie

Yes No
By signing this form, I declare that the information provided is true and correct. I have read and understand the Covid 19 protocol and agree to abide by its terms.
Signature

Clear
Date

Day Month Year
Should be Empty: