COVID FORM

COVID-19 DECLARATION FORM

Please complete this form in advance of your session
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Email*
example@example.com
Have you experienced any of the following symptoms in the past 21 days? Symptoms: cough, fever, loss of smell, loss of taste, general cold and flu symptoms*

YesNo
If yes, which symptoms?

CoughFeverLoss of tasteLoss of smellGeneral cold and flu symptomsOther
Have you been in contact with anyone with any of these symptoms - fever, cough, loss of smell or taste, general cold and flu symptoms?*

YesNo
Have you travelled internationally in the past 21 days?*

YesNo
Have you travelled or been in Sydney or outside the Northern Rivers region in the past 21 days?*

YesNo
Have you travelled interstate in the past 21 days?*

YesNo
If you have answered yes to any travel questions please document details below
Have you been in contact with anyone that has travelled (internationally, within NSW or interstate) within the past 21 days?*

YesNo
If yes, please provide details.
Have you had a COVID-19 test performed in the past 21 days?*

YesNo
If yes to COVID-19 testing - what was your result?
CONSENT
I full name* declare all the information provided above is true to the best of my knowledge.
I full name*agree to The Health Lodge's infection control policies. Including temperature checks, hand hygiene and mask protocol.
Ifull name* will immediately inform The Health Lodge if any of my answers change and understand this may impact my appointment.
Signature*

Clear
Should be Empty:

COVID-19 DECLARATION FORM

CONSENT