Vaccination Clinic : Kyabram District Health Services Intranet

First Name *

Last Name *

Contact Number *

Names of accompanying children (if applicable)

Have you been a primary or secondary close contact of a COVID-19 positive case in the last 14 days? *

Entry restricted, please contact Director of Clinical Service or Acute After Hours Manager on 5857 0200.

Have you visited an exposure site listed on the Department of Health website? *

Entry restricted, please contact Director of Clinical Service or Acute After Hours Manager on 5857 0200.

Do you have any symptoms of COVID-19 (fever/chills, sore throat, cough, runny nose, loss of smell or taste)? *

Entry restricted, please contact Director of Clinical Service or Acute After Hours Manager on 5857 0200.

Are you waiting for test results from a COVID-19 test? *

Entry restricted, please contact Director of Clinical Service or Acute After Hours Manager on 5857 0200.

Have you been diagnosed with COVID-19, and have not yet been cleared by the Department of Health? *

Entry restricted, please contact Director of Clinical Service or Acute After Hours Manager on 5857 0200.

Is your temperature under 37.5 degrees? *

Entry restricted, please contact Director of Clinical Service or Acute After Hours Manager on 5857 0200.

Please submit this form and present to reception for confirmation of form submission.