Patient Form

Name *

Surname *

E-Mail Address *

Contact Number *

Date of Birth & ID Number *

Have you travelled in the last 14 days? If yes, which place? *

Do you currently have flu like symptoms? *Select from the list...YesNo

Have you been exposed to anyone with the COVID-19 virus? *Select from the list...YesNo

Have you attended a healthcare facility where patients with COVID-19 infections are being treated? *Select from the list...YesNo

Have you experienced at least ONE of the following symptoms recently? *No symptoms at allCoughSore throatShortness of breathRedness of eyesBody achesLoss of smellLoss of tasteNauseaVomitingDiarrheaFatigueWeaknessTiredness

Have you been hospitalised recently with severe Pneumonia? *Select from the list...YesNo

I hereby declare to the best of my knowledge that the information disclosed is correct at the time of completion. I further undertake to inform THE PERSON THAT I AM VISITING should i be diagnosed with COVID-19 within the next 14-days so as to facilitate contact tracing. *

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