Covid Declaration Form

Declaration Form

Covid-19
Name

First NameLast Name
Mobile

Area codePhone Number
Date of Birth

MonthDayYear
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

YesNo
Have you been overseas or in contact with anyone who has been overseas within the past 14 days prior to your appointment

YesNo
Have you been in contact with anyone who has flu like symptoms within the last 14 days

YesNo
I agree to a temperature check and to abide by all the health and hygiene protocols stipulated by Janine Gaddie

YesNo
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

DayMonthYear
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