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CALL OR EMAIL FOR ANY ENQUIRY:
011 475 4070 OR debfprac@iafrica.com

COVID-19

Besonderhede Van Pasient / Patient Details

Besonderhede Van Hooflid / Details of Main Member of the Medical Aid

Naasbestaande wat nie by U woon nie / Next of kin who does not stay with you

Declaration

I, Ek, neem volle verantwoordelikheid om enige gelde verskuldng aan Dr. F.C. De Beer vir dienste gelewer te betaal / take full responsibility to pay any monies owing to Dr. F.C. De Beer for services rendered.

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Patient Questionnaire

Have you experienced or are experiencing any of the following symptoms during the last 7 days:

A fever

A dry cough

A loss of taste or smell

Sore muscles or joints

Fatigue or a feeling of being unwell

A sore throat

A shortness of breath

Had contact with anyone suspected that of having Covid-19

Travelled recently

Tested positive for Covid-19