eJoli Clinic COVID-19 before visit health screening questionnaire
Please fill all fields and answer all questions before you submit
Have you been experiencing or been in direct contact with any one who has any of these symptoms?
Cough
Fever
Sore throat
Loss of smell or taste
New occurrence of fatigue or body aches
Nausea or diarrhoea
Tested positive with COVID-19 within the last 3 weeks

Your Signature

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