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Torbay & Long Bay

Medical Centre

TORBAY MEDICAL

1042 Beach Rd, Torbay

09 477 9000

LONG BAY MEDICAL

55a Glenvar Ridge Rd, Long Bay

09 473 0063

PHONE: 09 477 9000
MON-FRI: 8.00am -5pm

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Covid-19 Health Declaration

How are you feeling today?

First Name

Last Name

Phone

Date of your appointment

Time of your appointment

PLEASE TICK TO CONFIRM ( IN THE LAST TWO WEEKS ) :

I do not have confirmed Covid-19.

I am not waiting for a Covid-19 test result

I and my household have not had known contact with Covid-19

I am not a Probable Case for Covid-19

I have not been asked to isolate.

I do not have runny/blocked nose, sore throat, cough

I do not have change in smell or taste

I do not have any flu like illness or fever

I have not been in a Managed Isolation Facility (MIQ) in the last 4 weeks

I have not been overseas in the last 4 weeks

I have received TWO doses of Covid-19 vaccine

PLEASE TICK TO CONFIRM :

I declare that the information I have provided is accurate and complete

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Torbay Medical Centre

1042 Beach Road, Torbay, 0630

09 477 9000

FOR EMERGENCIES

CALL 111

Long Bay Medical

55a Glenvar Ridge Rd, Long Bay

09 473 0063

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TORBAY MEDICAL

1042 Beach Rd, Torbay

09 477 9000

LONG BAY MEDICAL

55a Glenvar Ridge Rd, Long Bay

09 473 0063

PHONE: 09 477 9000 MON-FRI: 8.00am -5pm

Covid-19 Health Declaration

PLEASE TICK TO CONFIRM ( IN THE LAST TWO WEEKS ) :

PLEASE TICK TO CONFIRM :

PHONE: 09 477 9000
MON-FRI: 8.00am -5pm