COVID

COVID
Name

First NameLast Name
Do you have a confirmed diagnosis of covid?
Are you waiting for COVID test results, or considered a probable case, or been asked to self isolate?
Have you had close contact with anyone in the last 14 days who are probable or confirmed to have COVID?
Do you have new or worsening symptoms or an acute respiratory infection with atleast one of the following- cough, sore throat,shortness of breath, runny nose,shortness in breath, loss of smell,with or with out fever.
Have you travelled internationally within the last 14 day?
Have you had direct contact with someone in the last 14 days who has travelled overseas?
Have you had a COVID vaccine?
I answered yes to some of the above.I will let the appropriate person know of this as I won't be able to attend my appointment.
I (name)
can confirm that I answered No to the information I have provided above am happy to proceed with my appointment.
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Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
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