Your Name (required)

Your Email (required)

Phone (required)

Date

Have you been diagnosed with confirmed or suspected COVID-19 infection in the last 14 days? YesNo

Have you been in close contact with a confirmed or suspected case of COVID-19 in the last 14 days? YesNo

Are you awaiting results from a COVID-19 test? YesNo

Have you had any of the following symptoms in the past 14 days?:

• Cough
• Fever
• High Temperature
• Sore Throat
• Runny Nose
• Breathlessness
• Flu like symptoms
• Abdominal Cramping
• Diarrhoea
• Loss of Taste or Smell

YesNo

Have you been advised by a Doctor or the HSE to self-isolate due to COVID-19? YesNo

Have you been advised by a Doctor or the HSE to cocoon due to COVID-19? YesNo

Could you be classified as a person falling into the “at risk” Group around whom additional HSE guidelines apply? YesNo

Optional Message

I understand that this information is required for the purposes of public health and will be kept on file for a 2 month period from the date of signing.

I confirm that the above information is true and accurate from the date of signing.

I understand that my personal information including my name and contact details may be shared with the Health Service Executive (HSE) for the sole purpose of contact tracing in line with public health guidelines only if requested.

I consent to being treated, and accept that should I become infected, Sakara House cannot be held liable for transmission of COVID-19.

Click here to agree to the above conditions

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