Covid-19 Checklist

Please answer the following questions prior to your appointment. Thank you.

1 Step 1
1
YESNO
1. Do you have symptoms of cough, fever, high temperature, sore throat, runny nose, shortness of breath or flu like symptoms now or in the past 14 days?
2
YESNO
2. Have you been diagnosed with a confirmed or suspected COVID-19 infection in the last 14 days?
3
YESNO
3. Were you in close contact with a person who has a confirmed or suspected case of COVID-19 in the past 14 days?
4
YESNO
4. Does your current employment cause you to be in contact with someone who is suspected of having COVID-19?

5. Please provide details below of any other circumstances relating to COVID-19, not included in the above, which may need to be considered important to your upcoming appointment.

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