Dear customer, |
Here at Vitanova we are doing everything we can to prevent COVID-19 from spreading. When you visit our clinic, you must follow the instructions we give you with regards to: |
• Washing your hands with our hand disinfectant which will be available |
• Keeping your distance |
• Sneezing or coughing into your sleeve |
During this time, only patients receiving treatment can come into the clinic. Your partner or children will unfortunately not be allowed to accompany you. |
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Before we can attend to you at the clinic, we must first ask you to answer the questions below about COVID-19 |
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| First name:
* | |  |
| Last name:
* | | |
| Date of birth/Civil reg. no.:
* | | |
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| 1. Have you been sick within the last two weeks:
* | | |
| 2. Have you got a fever of over 37.5 degrees:
* | | |
| 3. Have you got a cough:
* | | |
| 4. Have you got a sore throat:
* | | |
| 5. Have you lost your sense of taste or smell:
* | | |
| 6. Have you been in contact with anyone else who has these symptoms:
* | | |
| 7. Have you been in contact with anyone who has COVID-19:
* | | |
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Declaration: by sending this form to us, you simultaneously confirm that you have answered all questions correctly. |
You also agree to contact Vitanova if after answering these questions you become sick or come into contact with somebody infected with COVID-19. |
You must not come to the clinic if you have symptoms. |
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Thank you for answering our questions. |
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