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.

Before we can attend to you at the clinic, we must first ask you to answer the questions below about COVID-19

First name: *
Last name: *
Date of birth/Civil reg. no.: *

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: *

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.

Thank you for answering our questions.