4th Avenue Coffee Roasters Parkhurst COVID-19 Questionnaire

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

First Name and Surname *

Contact Number *

Please Enter Your Temperature *

Residential Area (ie. Bryanston / Illovo) *

Have you experienced flu-like symptoms? Anything including a high fever, shortness of breath, sore throat/cough, tiredness, muscle pain, diarrhoea or any other digestive upset, loss of sense of smell or taste or any new skin conditions on toes and/or fingers. *

Yes

Have you tested positive for COVID-19 within the last 14 days? *

Yes

Have you been in contact with anyone who has tested positive for COVID-19 within the last 14 days? (Work or social) *

Yes

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms