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* 1. Please provide your Full Name and Date of Birth

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* 2. Please provide your contact details (Only 1 required)

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* 3. Please provide contact details of Partner (If applicable), or Other Support Person (If applicable) if they will be joining you. - We do ask that Clients come alone where possible to maintain social distance 

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* 4. Which Department will you be seeing

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* 5. Have you had close of casual contact with suspected or confirmed Covid-19 positive cases in the last 14 days?

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* 6. In the last 14 days have you been in a managed quarantine facility or self-isolating?

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* 7. Are you employed as a border worker or an international travel crew?

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* 8. In the last 14 days have you been requested by a healthcare professional to have a COVID test?

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* 9. Do you have any of the following symptoms: New Cough, Shortness of Breath, Sore Throat, Runny nose or High Temperature?

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* 10. Have you experienced any new loss of smell or taste?

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* 11. Would your support person (if applicable) or partner (if applicable) answer yes to any of the above questions?

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* 12. Please provide the date of your upcoming appointment

Date

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* 13. We ask that under Alert Level 2 and above that you wear a face mask at your appointments.

Please confirm that the above details provided are true and accurate.

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