Fever Clinic Registration Form
Health check questions
Do you have any symptoms?
*
Yes
No
Have you been contacted by the department of health regarding a COVID outbreak?
*
Yes
No
Are you a Health Care Worker in an aged residential health care facility?
*
Yes
No
Presenting as:
*
Public
Staff
Inpatient
Resident
Paramedic
Teacher
Health Care Worker
SVHM Department:
SVHM Employee number:
Location base:
Do you agree to be notified of test results via SMS?
*
Yes
No
Patient Details
UR or hospital number if known
Title
*
First Name
*
Last Name
*
Date of Birth
*
(dd/mm/yyyy)
Gender
*
Please choose an option...
indeterminate
male
female
other
Address Line 1
*
Address Line 2
Suburb
*
Postcode
*
Do you identify as Aboriginal or Torres Strait Islander?
*
Please choose an option...
Yes
No
Please provide at least one (1) contact number
Telephone - Home
Telephone – Mobile
Telephone - Business
Marital Status
Please choose an option...
Married
De facto
divorced
never married
seperated
unknown
widowed
Occupation / Employer
Religion
Country of Birth
Do you consent for your GP to be notified of your result?
Please choose an option...
No
Yes
GP or family doctor name:
GP or family doctor address:
Next of Kin details
First Name
*
Last Name
*
Relationship
Please provide at least one (1) contact number
Telephone - Home
Telephone – Mobile
Telephone - Business
Thank you for submitting the form.
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