Covid-19 Form

Prior to attending our office, please complete the following questions regarding any possible exposure to COVID-19.

If you answer “‘Yes’ to any of the following questions, you cannot attend our office and we will contact you to arrange an alternative.

Within the last 14 days, have you experienced a cough that you cannot attribute to another health condition? * Within the last 14 days, have you experienced a cough that you cannot attribute to another health condition? * Yes No

Within the last 14 days, have you experienced shortness of breath that you cannot attribute to another health condition? * Within the last 14 days, have you experienced shortness of breath that you cannot attribute to another health condition? * Yes No

Within the last 14 days, have you experienced muscle aches or soreness that you cannot attribute to another health condition or physical activity? * Within the last 14 days, have you experienced muscle aches or soreness that you cannot attribute to another health condition or physical activity? * Yes No

Within the last 14 days, have you had a high temperature or fever? * Within the last 14 days, have you had a high temperature or fever? * Yes No

Within the last 14 days, have you had close contact with anyone who has had or is suspected to have COVID-19? * Within the last 14 days, have you had close contact with anyone who has had or is suspected to have COVID-19? * Yes No

First Name*

Last Name*

Phone number *

Who will you be seeing? *

When attending our office, please note the following:

please maintain social distancing at all times;
you will have your temperature taken on arrival;
use the hand sanitiser provided at reception;
wear a face covering when unable to socially distance during your appointment;
limited refreshments will be offered; and
practice good hygiene at all times.