COVID-19 FORM - The Avenue

Name *

First

Last

Telephone Number *

Have you been in contact or living with anyone with a temperature above 38°C and/or has had a persistent cough?

Are you unusually fatigued or have new muscle pain?

Have you recently experienced shortness of breath?

Have you recently been out of the country and are currently undergoing the 14 day isolation?

Do you currently have any of the following symptoms?