Heritage Healthcare Visitor Booking Form

Heritage Healthcare Visitor Booking Form
Dear Visitor

Please note following changes with regards to visits:

All visitors are required to report to healthcare reception before the visit to complete the necessary screening. Please allow time for this.

The visiting rooms can accommodate a maximum of 2 visitors with the resident per time slot. Please book visits according to this.

The Inside Controlled Visits can accomodate 1 visitor per time slot per resident

Physical contact and touch is unfortunately not permissible at this stage. Please do not make any physical contact with the resident/patient.

Please do not bring any food items to the visiting room. Should you wish to bring an edible food gift, please hand in at the healthcare reception to be processed along with other deliveries.

Thank you for your co-operation.
Date*

MonthDayYear
Date
Visitor Name & Surname*

First NameLast Name
Visitor Email*
example@example.com
Visitor Contact details*

Area CodePhone Number
Visitor residential Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Visitor Id Number*
Have you been Vaccinated(Please note we only accept vaccinated visitors for visitations inside our healthcare, and we will be asking for proof of vaccination on visitation, Should you not be vaccinated, you are only allowed outside Visitation)*

NoYes
Relation to Resident/Patient*
Resident/Patient Name*

First NameLast Name
Visitation type: Please note the bookings for the outside area is weather dependent and we cannot accommodate these visits if the weather does not allow for it, neither are we able to make alternative arrangements)*

Visitation RoomOutside AreaInside Controlled Visits
Appointment - visitation room*
Appointment - Outside Area*
Inside Controlled Visits*
Should be Empty: