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Health Screening Form for Visitors

Naar Nederlands

    In an effort to reduce the risk of COVID-19 exposure to Viroclinics-DDL employees and visitors, all visitors must complete this Health Screening Form for Visitors:
    Full name:
    Phone number:
    Person / Department visiting:
    Do you currently have symptoms of, or have been diagnosed with, pneumonia or COVID-19?
    In the past 14 days, have you been in contact with or cared for someone who is or could be infected with COVID-19?

    In the past 24 hours, have you had any of the following symptoms?
    Runny nose
    Sore throat
    Shortness of breath
    Visitors who answered ‘’yes’’ to any of the above questions will not be permitted access to Viroclinics-DDL's facilities.
    By filling out this Health Screening Form for Visitors, the visitor expressly acknowledges and agrees in sharing this information with Viroclinics-DDL upon their specific request for the sole purpose of tracing in case of a possible local spread of the COVID-19 virus. These data and information will be deleted after 14 calendar days.

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    To learn more about our sister company Viroclinics
    please visit: www.viroclinics.com