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Declaration of health
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The purpose of this form is to minimize the risk of potential infectivity regarding COVID-19. This form is required to fill in one day prior to the scheduled appointment.
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1.
Question 1.
Have you had a cough in the last two weeks?
Required
- Required.
Yes.
No.
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2.
Question 2.
Have you had a temperature in the last two weeks?
Required
- Required.
Yes.
No.
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3.
Question 3.
Have you had any unusual symptoms for last weeks?
Required
- Required.
Yes.
No.
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4.
Question 4.
Have you been in contact with anyone with COVID-19?
Required
- Required.
Yes.
No.
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5.
Question 5.
Have you been visiting any countries where COVID-19 is endemic in the last 2 weeks?
Required
- Required.
Yes.
No.
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6.
Question 6.
Have you had a SARS-CoV-2 antigen test? What was the result? (It is required to do this test one day prior to the scheduled appointment)
Required
- Required.
Positive
Negative
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7.
Question 7.
Your name
Required
- Required.