Covid-19 Screening Form

Please complete Within 24hrs of your Appointment

Did you have any of the following symptoms (and are they out of the ordinary for you) in the past 14 days? if you answer "yes" to any of the questions, we will have to postpone your appointment, please call your GP and contact us to let us know.
Have you been diagnosed with confirmed or suspected Covid-19 infection in the last 14 days?
Have you been in close contact of a person who is a confirmed or suspected case of Covid-19 in the past 14 days (ie less than 2 metres for more than 15mins in 1 day)
Have you been advised by a doctor to self-isolate or cocoon in the last 14 days?

If you answer Yes to any of the prior questions please contact us to rearrange your appointment.

Thank you for your time, keeping Ireland safe.

Your Signature

© 2020 by Zephan MacBennet