Covid Forms – Marta Magic Mind

Covid-19 Form

Name

Address

1. Do you have symptoms of cough, fever, high temperature, sore throat, runny nose, breathlessness, flu like symptoms or loss or change to your sense of smell or taste now or in the past 14 days?

2. Have you been diagnosed with confirmed or suspected COVID-19 infection in the last 14 days?

3. Are you a close contact of a person who is a confirmed or suspected case of COVID-19 in the past 14 days ?

4. Have you been advised by a doctor to self-isolate at this time?

I certify that the above facts are true to the best of my knowledge.