COVID-19 Form

Name *

Email *

Number *

Address *

Have you recently, or are currently experiencing the following symptoms, please tick? *

Have you travelled internationally within the past 14 days? *

Have you travelled interstate within the past 14 days? *

Have you come into contact with any suspected, probable or confirmed Covid-19 cases with in the last 14 days? *

Are you currently living with someone who is mandatory or voluntarily self-isolating due to being in contact with a confirmed case of Covid-19 or a suspected case of Covid-19? *

Have you visited a hot spot as listed by SA health? *

How did you find us? *

Today's Date *

I agree to follow strict hygiene practices while at my appointment including washing or sanitizing my hands on arrival, and will comply with staff instructions during my service. I agree to maintain physical distance from the reception desk and non-clinical staff. I understand that in the current, fast-moving climate my appointment may need to be rescheduled with very short notice. If this occurs a new appointment will be found in line with government guidelines

Tick to sign that you agree *

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