Covid-19 Screening Form
We would be grateful if you could complete and submit this form on the morning of your appointment, prior to you attending.
Full Name
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Select any that apply to you
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In the last 24 hours I have developed a cough
In the last 24 hours I have developed difficulty breathing / shortness of breath
In the last 24 hours I feel hot to touch on my back and/or chest
In the last 24 hours my sense of smell and taste have changed
In the last 24 hours I have unexplained fatigue and/or malaise
In the last 24 hours I have been ordered to self isolate
In the last 24 hours I have had treatment for COVID-19
None of the above
Based on your responses you should stay at home & self-isolate
We will contact you and plan the next steps.
There are on-line consultations available.
Seek prompt medical attention if your illness is worsens (e.g. difficulty breathing, continous fever).
Based on your responses please continue to come to the clinic for your appointment.
Maintain 2 meter distance between you and everyone else.
Please do not bring friends, children or family members with you, unless you have pre-arranged a chaperone and/or escort with us, please contact the clinic regarding this.
On arrival, please ring the bell and wait to be let in. Do not walk straight into the clinic. We may ask you to wait outside until our staff is ready to see you.
If you need to cough or sneeze, please cover your mouth and nose with your elbow and do not wipe your hands on anything.
Disinfect your hands with sanitiser before and after your consult.
We may ask you to wear at mask.
Thank you.
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