COVID-19 Survey

Do you live in Sydney *

Are you worried that you may have COVID-19? *

Do you have symptoms of COVID-19?

Have you been in contact with someone who may have COVID-19? *

Date of birth *

Name *

First

Last

Required as it appears on your Medicare Card

Phone *

Required for contact

Gender *

As recorded on Medicare

I consent to the clinic contacting me by SMS for the purpose of health information, test kit delivery and test results *

Phone