COVID-19 Questionnaire

COVID-19 Screening Questionnaire
Please tick any of the following conditions which apply to you *
Have you been in contact with anyone with suspected or proven COVID-19? *
Please tick any of the following symptoms that you are currently experiencing *

I solemnly and sincerely declare that the information I have provided is true and correct and I make this solemn declaration conscientiously believing the same to be true. If any person should suffer as a result of the information being found to be untrue and false the I am aware that i can be prosecuted for making a false declaration. I agree to my details being sent to the correct authorities should they need to be for track and trace purposes.

Please tick below to acknowledge that you have read and agree to the above declaration *