COVID-19 PRE-SCREENING QUESTIONNAIRE

This questionnaire is intended only for clients who have a confirmed appointment time and is to be completed on the day of their appointment.

We are a registered NSW COVID-SAFE business. The safety and well-being of our clients is of utmost priority to us. Working together to help fight the spread of COVID-19 is important to us, so that we can continue our service, to every client including you, safely.

As part of our precautionary measures during these challenging COVID-19 times, please kindly fill in the following pre-screening questionnaire PRIOR to our arrival on your appointment day. This will greatly assist us in ensuring that no one in the premise (clients, visitors and our employees) are exposed to potential virus risk.

Thank you for your understanding and cooperation.

*Please refer to our Privacy Policy for details on how your personal information collected below is used within our practice.

First Name*

Last Name

COVID-19 PRE-APPOINTMENT DECLARATION *

I CONFIRM THAT:

I have not been overseas or interstate in the past 14 days.I have not been to any of the current hotspots or the exposure venues (per NSW Health advice) in the past 14 days.I have not been in direct contact with a confirmed or suspected case.I have no symptoms of the COVID-19 virus, including fever, cough, sore throat, shortness of breath, loss of smell and loss of taste.I am not currently awaiting test results for COVID-19 (during which I am required to be in self-isolation).I have not tested positive for COVID-19.I am not immunocompromised or in close contact with someone who is.

Please Call Us on 0450 505 031 To Discuss a Reschedule of your appointment if you are unwell or experiencing any Flu-type Symptoms Or Have had an Exposure Risk to Covid-19. THANK YOU.

ADDITIONAL NOTES:

Appointment Date*

Signed by *

Please type your name and it will be taken as your digital signature for the purposes of this online questionnaire.

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