Your Name (required) Who Are You Filling This Out For? (required) MeFor Somebody Else Your Email (required) Contact Number (required) Do you believe you may currently have Covid-19? YesNo Do you have symptoms of cough, fever, high temperature, sore throat, runny nose, breathlessness or flu like symptoms now or in the past 14 days? (required) YesNo Have you been diagnosed with confirmed or suspected COVID-19 infection in the last 14 days (required) YesNo Are you a close contact of a person who is a confirmed or suspected case of COVID-19 in the past 14 days (i.e. less than 2m for more than 15 minutes accumulative in 1 day) (required) YesNo Have you been advised by a doctor to cocoon or self-isolate at this time? (required) YesNo Signed (required)
