COVID-19 Questionnaire

The Mind Body Practice collects limited personal information from visitors to the facilities for risk and screening purposes in accordance with Public Directions/Orders. Collection of personal information for this purpose will be managed in accordance with Public Directions/Orders and the Privacy Policy, a copy of which is available at or upon request.
Email address *
Full Name *
Mobile Number *
Are you attending with children? *
Where you live (enter postcode) *
Where you work (enter postcode) *
Are you currently in a period of self-isolation following a positive COVID-19 test *
Have you been in close contact with a confirmed COVID-19 case in the past 14 days? *
Have you been formally identified as a close contact of a confirmed case? *
Are you unwell with any cold or flu like symptoms including: fevers, cough, vomiting, diarrhoea, night sweats or chills, or acute respiratory infection including cough, shortness of breath or sore throat? *
Have you travelled to an identified hotspot as identified here ( in the last 14 days? *
Have you returned from Victoria, overseas or from a cruise in the last 14 days? *
A copy of your responses will be emailed to the address you provided.
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