COVID 19 TRIAGE

COVID 19 TRIAGE

Covid-19 Triage

Name*
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date of Birth
Date Format: MM slash DD slash YYYY
Email*
Phone*
GP Name*
Have you been sick in the last 2 weeks?*
Do you have fever (over 37,5°C)?*
Are you coughing at present?*
Do you have a sore throat?*
Have you lost your sense of smell or taste?*
Have you been in contact with somebody who has any of these symptoms?*
Have you travelled to an area at high risk for COVID-19, nationally or internationally?*
Do you work in a hospital/nursing home or healthcare facility?*
Have you been in contact with somebody that has COVID-19?*
Were you diagnosed with COVID-19?*
Do you live in a household with somebody who has been diagnosed with COVID-19 infection or has COVID-19 symptoms (fever, cough, loss of smell)?*
If you have been COVID-19 positive and recovered, do you have certified medical evidence of clearance?*
Do you have a severe medical condition like diabetes, respiratory disease, chronic kidney disease, etc.?*
Contact Permission
I Agree to be contacted by phone & email in relation to this enquiry*
- YES
Patient Database Protection Permission Agreement
To facilitate your patient care, we need your permission to contact you and any other medical service providers agreed with you, during the course of your treatment, by email, SMS, phone and other electronic means. We'll always treat your personal details with the utmost care and will never sell them to other companies for marketing purposes. All personal data which is emailed, is encrypted, password protected & GDPR compliant
Date
Date Format: MM slash DD slash YYYY

Covid-19 Triage

Contact Permission

Patient Database Protection Permission Agreement