SelbstauskunftCOV19

Self-disclosure COVID-19

Have you or relatives traveled through cities, states or regions during the last 14 days, that are subject to the quarantine regulations of the local or federal government?

YES NO

Have you had contact with a confirmed COVID-19 patient in the last 14 days or a family member in a shared household affected by an official quarantine?

YES NO

Have you recently noticed symptoms of the COVID-19 infection (cough, fever, difficulty of breathing, loss of taste)?

YES NO

First name

Last name

Date of birth

Mobile phone

Purpose of visit:

Clinic Physiotherapy

I hereby explicitly agree with the use of my personal data for the purpose of processing a COVID-19-antigen-test. I confirm the correctness of my personal data and declare my agreement to store and use these data in a legally manner.

Repeat the characters from above.

In the next step you will confirm the authenticity of your disclosure by entering the code that we will send you via SMS to the phone number you provided (please recheck the number).