Health Check Questionnaire

Questionnaire

* Indicates required field

Name *

First

Last

Email *

Phone Number *

Booking Date *

As per Government guidelines the most important symptoms of coronavirus (COVID-19) are recent
onset of any of the following:

Have you or has anyone else you live with experienced any of the above symptoms (in the last 14 days)? *

Are you or is anyone you live with awaiting a result on a test on COVID-19? *

Have you or has anyone else you live with ested positive for COVID-19 (in the last 14 days)? *

Submit