Covid Screening Form

Name*

First NameLast Name
Date of Birth*

DayMonthYear
Mobile phone*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com

Patient Covid-19 Screening
Have you tested positive for COVID-19 in the last 7 days?*

yesno
Are you waiting for a COVID-19 test or the results?*

yesno
Do you live with someone who has either tested positive for COVID-19 or had symptoms of COVID-19 in the last 14 days?*

yesno
Do you have any of the following symptoms:

New, continuous cough*;High temperature or fever;Loss of, or change in, sense of smell or taste?
* A new, continuous cough means coughing for longer than an hour, or
three or more coughing episodes in 24 hours. If the patient usually has a
cough, it may be worse than usual.

If you have answered YES to any of the above, you should not attend the practice.

If you have recovered from COVID-19, or completed a period of self-isolation, you are able to attend the practice.

A person is considered to have recovered from COVID-19 infection when
they meet all of the following criteria:
• It has been at least 7 days since the onset of the COVID-19 symptoms;
• They no longer have a high temperature.
N.B. A cough may persist for several weeks in some people, even though the coronavirus infection has cleared. The loss of, or change in, sense of smell or taste may also linger. According to the CMO letter (18 May 2020) a person with a persistent cough and/or loss of sense of smell or taste but no other symptoms does not need to continue to self-isolate for more than 7 days.
I hereby declare that the information provided is complete and accurate. I fully understand that any false information can put the healthcare workers attending to me at a higher risk of contracting COVID-19 disease. I fully agree to follow all the instructions regarding precautionary steps by the treating clinician and staff at the clinic.
I am visiting the clinic with full knowledge that we are going through a COVID-19 global pandemic.
There is always a risk of contracting this virus when I am visiting a place during this pandemic.
There is a possible risk of getting this virus by visiting any place during this pandemic. I have been fully explained the content of this declaration form in a language that I can understand.
I hereby absolve the treating clinician at 656 Aesthetics of any criminal or medicolegal liability arising due to my visit to the clinic. I hereby give my consent for this.
Signature*

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