COVID Screening Form - Marina Inez Pilates

Please complete and submit the following form before entering the studio. Once submitted please show me the completion screen.

Name

First Last

Email*

Mobile Phone*

Have you had any of the following COVID-19 symptoms over the past 14 days?*

Persistent Cough, Shortness of breath, Fever, Chills, Repeated Shaking, Fatigue, Muscle Aches, Vomiting, Headaches, Sore throat, Loss of taste or smell, Malaise, Nausea, Diarrhoea

Yes
No

Are you awaiting lab test results for COVID-19?*

Yes
No

If yes, when were you tested?*

Have you or a family member within your household been contacted by the Government's Track and Trace team?*

Yes
No

Have you travelled to a high risk area anywhere in the World in the last 14 days?*

Yes
No

Have you been asked to shield by the Government or your GP?*

Yes
No

IF YOU HAVE ANSWERED YES TO ANY OF THE QUESTIONS WITHIN THIS FORM, PLEASE DO NOT ENTER MARINA PILATES STUDIO. PLEASE GO HOME AND SELF ISOLATE ACCORDING TO THE GOVERNMENT'S INSTRUCTIONS.

Email

This field is for validation purposes and should be left unchanged.