Fillable Victoria State Coronavirus (COVID-19) consent form

Fill Online, Printable, Fillable, Blank Victoria State Coronavirus (COVID-19) consent form Form

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Victoria State Coronavirus (COVID-19) consent form

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The Victoria State Coronavirus (COVID-19) consent form form is 1 page long and contains:

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  • 6 check-boxes
  • 6 other fields

Country of origin: AUSTRALIA
File type: PDF

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Coronavirus (COVID-19) consent form
Coronavirus disease (COVID-19) – getting tested when you do not have symptoms
(asymptomatic testing). What you need to know
□ I have read and understood the attached information sheet and consent to be tested
for COVID-19 under the asymptomatic testing program for healthcare workers
This form below requires your contact details and contains brief questions on any current
symptoms you may have. Providing your contact details will help your health service contact
you with your test results.
Full name
Date of birth
(DD/MM/YY)
Do you identify as:
Select one:
□Neither Aboriginal nor Torres Strait Islander
□ Aboriginal but not Torres Strait Islander
□Torres Strait Islander but not Aboriginal
□ Aboriginal and Torres Strait Islander
□Prefer not to say
Residential address
Contact number
Email
Please specify where
the test was taken
Campus:
Health service:
Date of test
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Victoria State Coronavirus (COVID-19) consent form

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Completed 10 May 2020

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