Covid-19 Declaration Form – Larianae Notaries

Covid-19 Declaration

You will understand that we need to take steps to protect you and us from the risks posed by COVID-19 (coronavirus). We ask you to complete this form if you are attending our premises for this purpose. The information you provide will be kept in strict confidence and only be used/retained/disclosed for purposes related to our response to COVID-19, including the sharing of data, if required with healthcare professionals, governmental authorities, insurers and on a need to know basis within our organisation, in line with our usual policies.

Name

First Name *

Last Name *

Contact Information

Contact Phone Number *

Email *

1. Have you been to, or been in close contact with, anyone who has been abroad in the past 14 days?

Answer *

2. Have you in the past 14 days been exposed to someone that has tested positive or is displaying symptoms of COVID-19 symptoms, including: a high temperature; a new, continuous cough; or loss or change to your sense of smell or taste?

Answer *

3. Do you have any of the symptoms of COVID-19, including: a high temperature; a new, continuous cough; or loss or change to your sense of smell or taste?

Answer *

If you have answered yes to any of the above questions, and have further information you think we should know, please type it below.

(duplicate)

Unfortunately, we may not be able continue with your appointment depending on your answers above or if you do not provide us with a completed form. We trust you will understand the need for these unusual measures.

I understand, and my replies to the above are true to the best of my knowledge and belief. *

YesNo