COVID Screening | Kate Allen

COVID Pre-screening Questionnaire to be completed prior to your appointment.

First Name*

Last Name*

Email*

Date/Time of my appointment*

Are you double vaccinated?*

Indicate if you have had any of the following signs or symptoms, in the last 14 days:

Fever*

Body aches*

Abdominal pain*

Feeling tired and unwell*

Cough*

Breathlessness*

Runny nose*

Sore throat*

Loss of smell*

Diarrhea*

Red eyes*

Skin rash or discolouration of fingers or toes*

Do you suffer from seasonal allergies e.g. hayfever?*

Do you have any contacts with known COVID symptoms?*

Are you a contact for COVID?*

Have you been tested for COVID in the last 48 hours?*

Have you been required to self-isolate in the last 14 days?*

Have you visited a location of interest in the last 14 days?*

Do you have any contacts who have been tested for COVID in the last 14 days?*

Have you had COVID?*

Have you travelled out of Auckland in the last 14 days (including overseas travel)?*

Have you been in MIQ or any form of isolation in the last 14 days?*

Understand*

I understand I must attend my appointment alone (no support people or children allowed during Level 3). I also understand that I should wait in my car until 5 minutes prior to my appointment and will scan in using the displayed QR code.*

Declare*

I declare the above to be true and I fully understand that there is a very small chance, despite all possible precautions being taken by Kate Allen, that I could be exposed to or contract COVID by attending this appointment. I give permission to Kate Allen, to give my details to the appropriate authorities should this be required for contact tracing.

kateallen.co.nz

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