I understand that the novel coronavirus causes the disease known as COVID-19.
I understand the novel coronavirus has a long incubation period during which the carriers of the virus may not show not show the symptoms and may still be contagious.
I understand that : physical distancing of 1.5 metres may not be possible everytime.
if they are deemed unsafe to myself or a staff member I may NOT bring children or anyone else who does not have an appointment.
I understand the staff will do everything possible to minimise the spread of COVID-19, but will not hold them responsible should I contract COVID-19.
I confirm that: I am not currently positive for COVID-19.
I am not waiting for the results of a laboratory test for COVID-19.
I have not returned to here from any other State or Country, whether by car, air, sea, bus or train in the past 14 days.
I have not been identified as a contact of someone who has test positive for COVID-19 or been asked to self-isolate by any government agency.
I am not in high risk category for increased illness or death from COVID-19, including : diabetes, cardiovascular disease, hypertension, lung disease including moderate to severe asthma, being immunocompromised (including transplant recipient), having active malignancy or over the age of 65.
I am NOT presenting with any of the following symptoms of COVID-19:
- Fever > 38C, or 100F, chills or body aches
- Cough
- Sore Throat
- Shortness of breath / Difficulty breathing
- Flu-like symptoms
- Runny Nose
- Loss of smell or taste
I will immediately notify the authorized person if I contract the virus within two weeks following my visit.
By signing below, I verify that the information I have provided on this form is truthful and accurate.