Covid-19 Health Screening: GHCC Counselling Request
This screening questionnaire is to be completed before arriving at any GHCC Campus. You are required to ensure that the screening is as accurate as possible.

For emergencies please contact us at (021) 703-9400 or email us at info@ghcc.tv
Personal info
Please provide all the required details for your booking to be logged.
Full Name & Surname *
Phone number *
Email address
Select Region *
Please provide a brief description of counseling needs here eg. Marriage, etc.
Have you been in contact in the last 14 days with someone who is suspected to have Covid-19? *
Have you been in contact in the last 14 days with someone who is confirmed to have Covid-19? *
Have you attended/ visited a healthcare facility that has treated patients with COVID-19 in the last 14 days? *
Are you currently suffering from any of the following symptoms? *
Required
I hereby declare to the best of my knowledge that the information disclosed is correct at the time of completion. *
Submit
Never submit passwords through Google Forms.
This form was created inside of GHCC. Report Abuse