Covid-19 Visitor Form

1

Full NamePlease enter your full name

First Name

Last Name

2

EmailPlease enter your email address

example@example.com

3

Telephone numberPlease enter your telephone number

4

VisitingWhich home are you visiting?

5

Have you been in contact with or are living with someone suspected or confirmed of having Covid-19 within the past 10 days?

YESNO

6

Do you have a fever, or have you had a high temperature in the last 10 days (a fever is a temperature greater than 37.8 °C?)

YESNO

7

Have you had a loss of or change in your normal sense of smell in the last 10 days?

YESNO

8

Have you had a cough or any other respiratory signs in the last 10 days?

YESNO

9

Do you suspect you have had COVID-19?

YESNO

10

How many days ago did the symptoms start?

11

Any Covid-19 risks identified

12

As you have selected yes to one of the questions above we must consider your responses before we allow you to visit our home.

Please DO NOT visit the home until you have spoken with a manager in response to this form.

Thank you for your understanding during this difficult time.

13

Signature

Clear