Surveypoint

Q1

First Name

Patient's Name

Q2

Last Name

Patient's Name

Q3

Email

Q4

Phone Number

Q5

Age

Q6

Street Address

Address

Q7

Street Address Line 2

Address

Q8

City

Address

Q9

State / Province

Address

Q10

Postal / Zip Code

Address

Q11

Please select the doctor that you would like to see.

Doctor Name 1

Doctor Name 2

Doctor Name 3

Doctor Name 4

Q12

In the past 14 days, have you or the the patient traveled or lived in area with a probable/ confirmed case of COVID-19?

Yes

No

Q13

In the past 14 days, have you or the the patient contacted closely with probable/ confirmed case of COVID-19?

Yes

No

Q14

Which of the following symptoms have you or the patient experience in the past 14 days?

Fever

Cough

Sore Throat

Shortness of Breath

Difficulty of Breathing

Diarrhea

Eye Itch

Please Specify

Q15

Which of the following conditions apply to you or the patient?

60 years old or above

with pre-existing medical conditions (Asthma, Liver Disease, Diabetes, Chronic Lung Disease, etc.)

Diagnosed as high-risk pregnancy

Health worker

Q16

Pre Appointment Declaration Form -Form Fill

First Name

Last Name

Email

Phone Number

Age

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Please select the doctor that you would like to see.

In the past 14 days, have you or the the patient traveled or lived in area with a probable/ confirmed case of COVID-19?

In the past 14 days, have you or the the patient contacted closely with probable/ confirmed case of COVID-19?

Which of the following symptoms have you or the patient experience in the past 14 days?

Which of the following conditions apply to you or the patient?

Patient's Signature