Filling the Gap/ADHF Clinics
Filling the Gap/ADHF Clinics
Pre-screening is required for all patients prior to your appointment.
Patient Name
*
Patient Postcode
*
Caseworker
*
Caseworker Contact
*
Please answer these questions truthfully
Please answer these questions truthfully
Have you tested positive to COVID-19 within the last 10 days?
*
YES
NO
Have you tested positive to another acute respiratory infection in the last 7 days?
*
YES
NO
Do you have any symptoms of COVID-19 or other acute respiratory infection?
*
YES
NO
Have you been identified as a high risk contact of someone who has had COVID-19 in the previous 7 days?
*
YES
NO
Have you returned from overseas in the past 7 days?
*
YES
NO
I consent to my data being collected and stored as per ADA NSW privacy policy
*
I consent to my data being collected and stored as per ADA NSW privacy policy
*
*
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