Field is required!
Field is required!
Field is required!
Field is required!
Field is required!
1. Have you lived / visited in the last month areas / countries where there were people suffering from COVID-19 infection?
Field is required!
2. Have you come into direct contact with people who, in the last month, have lived / visited areas / countries where there were people suffering from COVID-19?
Field is required!
3. Have you been in contact in the last month with patients diagnosed with COVID-19 or with suspected COVID-19 infection?
Field is required!
4. Have you been hospitalized in the last 30 days?
Field is required!
5. Do you have a diagnosis of neoplasm / treatment with cytostatics or other medical conditions that lead to decreased immunity?
Field is required!
6. Have you had one or more of the following symptoms in the last 30 days?
Fever
Field is required!
Cough
Field is required!
Headache
Field is required!
Difficulty breathing
Field is required!
Difficulty swallowing
Field is required!
Fatigue installed without explanation
Field is required!
7. Have you been recommended to stay isolated at home for the last 14 days?
Field is required!
8. Have you been positively diagnosed with COVID 19 infection or have you been declared HEALED by COVID19?
Field is required!
Consent
I hereby give my consent, in accordance with Regulation (EU) 679/2016 of the European Parliament and of the Council of 27.04.2016, on the protection of physical personal data regarding the processing of personal data and on their free movement.
I declare on my own responsibility that the data and information provided to the medical staff are real and correct.
Your signature (Patient or belonging)
Draw it with your finger or with your computer mouse in the box bellow

Va rugam semnati
Trimite