Zelus Registration / Self declaration form-Covid 19

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Full Name *

Phone number *

Email *

Date of Birth DD/MM/YYYY *

Address *

I am not residing in any containment zone. I am not suffering from fever, cough or cold. I am not under quarantine. I have not tested COVID -19 positive in last one week. *

I acknowledge

Required

I am competent to give and hereby give my informed consent for clinical and physical examination of the above named patient, for conduct of investigations deemed necessary and for treatment of the said patient by medical staff at Zelus Healthcare. I hereby declare that all the entries made above are true, correct and fair to the best of my knowledge. *

YES

Required

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