Attendance Registration Short

Name (required)

I am a (required)
PatientCarer accompanying patientProfessional VisitorDigestive Health Staff

Approximate Length of stay (required)
less than 15 minutes30 minutes1 hour3 hoursmore than 3 hours

Phone number (required)

Do you have any of the following symptoms Cough, Sore throat, Shortness of breath, Chills, Recent loss of sense of smell or taste, any other respiratory symptoms?

YesNo

If Yes, please list your symptoms here:

Are you currently required to self-isolate or quarantine, or awaiting a COVID-19 test result (except if you are part of a surveillance program)?

YesNo