Covid-19 Declaration Form Order Number Full Name Mobile Number Area Visiting Date of Visit Have you visited any of the countries outside Ireland excluding Northern Ireland? * Yes No Are you suffering any flu like symptoms/symptoms of coronavirus? * Yes No Are you experiencing any difficulty in breathing, shortness of breath? * Yes No Are you experiencing any fever like/temperature symptoms? * Yes No Did you consult a Doctor or other medical Practitioner? * Yes No How are you feeling Healthwise? * Well Unwell Have you been in contact with someone who has visited an affected region in the past 14 days? * Yes No NOTE: When on site, please adhere to our on-site standard processes/procedures regarding infection control, i.e. hand washing/hand sanitising and general coughing/sneezing etiquette? I agree to allow Thurles Leisure Centre to store my data. * Yes
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