Name *

First Name

Last Name

Have you had a fever (more than 38 degrees)? *

Yes

No

Have you had a cough? *

Yes

No

Have you had shortness of breath? *

Yes

No

Have you had a sore throat? *

Yes

No

Have you been in contact with anyone with these symptoms? *

Yes

No

Have you been in contact with anyone who has tested positive to the Covid-19 infection ? *

Yes

No

Have you travelled outside of WA or been in contact with anyone who has in the past 14 days? *

Yes

No

I have answered the following questions correctly and understand my appointment will need to be rescheduled if I have selected Yes to any of the above questions . Appointments will only be confirmed once this form has been submitted and approved. If you experinece any of these symptoms in the days leading up to your appointment or the day of your appointment please call us to reschedule. No cancelation fee will apply . *

Agree

Disagree

I consent to having my temperature checked on arrival to my appointment and agree that if is above 38 degrees that my appointment will be rescheduled. *

Agree

Disagree