COVID-19 Patient Screening
For all of our safety, please fill this out prior to entering the surgery (until further notice). Be sure that the information you'll give is accurate and complete. Please get immediate medical attention if you have any of the severe COVID-19 signs.
Name
*
First Name
Last Name
Email
example@example.com
Phone Number
*
-
.
In the past 14 days, have you...
*
Rows
Yes
No
Unsure
Had any symptoms of Covid-19 in the last 14 days?
Been diagnosed with Covid-19
Travelled Abroad
Been advised to self-isolate
Been a confirmed close contact
In the past 14 days, I have experienced...
Rows
Yes
No
Fever 38°C +
Unexplained body aches or pain
Coughing
Sore throat
Shortness of breath
Chills with or without body aches
Recent loss of sense of smell or taste
Unexplained sores on soles of feet
Unusual fatigue
Non-allergy related runny nose
Been told to self isolate
Been diagnosed with Covid-19
Been in contact with a confirmed Covid-19 case
Signature
Submit
Should be Empty: