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COVID-19 Check & Registration

Because of the current coronavirus measures, we’re obliged to ask you the following health-related questions upon arrival. Furthermore, we also request you to leave behind your contact information. The information will be used to warn you in case of an outbreak of COVID-19.

Fields marked with an asterisk (*) are mandatory.

Symptom Check

1. Did you have one or more of these complaints in the past 24 hours?

  • Coughing
  • Symptoms of a common cold
  • Fever or elevated temperature
  • Shortness of breath
  • Loss of taste and smell

 

2. Does someone in your household have a fever and/or shortness of breath?

 

3. Did you have the coronavirus and has it been diagnosed in the past 7 days (in a laboratory)?

 

4. Do you have a roommate/family member with the new coronavirus and have you had contact with him/her in the past 14 days while he/she still had complaints?

 

5. Are you in quarantine because you had direct contact with someone who has been diagnosed with the new coronavirus?


Contact Information


Consent

My data may be used for source and contact research of the Municipal Health Services (GGD). My data may be shared to third parties that legally require it (e.g. restaurants and cafes).


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