Health Screening Form Stable Health
Clinic Attendance Register
Which clinic are you visiting? *
First and last name: *
Best contact phone number: *
Best contact email address:
Are you experiencing any flu-like symptoms? (Sore throat, fever, shortness of breath, cough and/or loss of smell/taste) *
If you answered YES, please clarify:
Have you had contact with a confirmed or probable case of COVID-19? *
Have you ever been diagnosed with COVID-19? *
Declaration: *
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