Visitors Covid-19 Health Questionnaire

Updated: 09/10/2020

The safety of our residents, staff and visitors remain our overriding priority. To prevent the spread of Covid-19 and reduce the potential risk of exposure to everyone, we are conducting a simple screening questionnaire. Your participation is important to help us take precautionary measure to protect our residents, staff and visitors.

All visitors are expected to follow our guidelines including wearing of a face mask, which covers the nose and mouth at all times, and also follow social distancing rules by keeping 1 meter apart. Please remember to avoid physical contact including shaking hands.

Please complete this form below, or use the button at the top of the page to print and manually fill in the form before starting your visit

1. Have you experienced any cold or flu -like symptoms in the last 14 days (to include fever, cough, sore throat, respiratory illness, difficulty breathing) 1. Have you experienced any cold or flu -like symptoms in the last 14 days (to include fever, cough, sore throat, respiratory illness, difficulty breathing) Yes No

2. Have you had close contact with, or cared for, someone diagnosed with Covid-19 within the lat 14 days? 2. Have you had close contact with, or cared for, someone diagnosed with Covid-19 within the lat 14 days? Yes No

3. Have you returned from any of the countries reported to be infected according to the WHO with documented Covid-19 transmission within the last 14 days? 3. Have you returned from any of the countries reported to be infected according to the WHO with documented Covid-19 transmission within the last 14 days? Yes No

4. Full Name

5. Phone Number

6. Email Address

15 + 6 =

Please Note:

This form should only be filled in and submitted on the day of your visit. You will also be required to have your temperature recorded upon your visit. Please ensure you are also familiar with our Guide to Visiting Relatives During The Covid-19 Pandemic