Concerned that you have contracted the COVID19 virus?

Please complete the form below or mail us on

We will get back to you as soon as possible with details on how to proceed.

Stay Safe and Healthy – wash your hands regularly – use hand sanitizer whenever possible.

Your Name (required)

Your Email (required)

Your Cell/Contact Number (required)

Any concerns about COVID-19 / Flu like symptoms?

Recent Travel outside of SA?- To high risk areas - name country/s

Contact with a known case of COVID-19 If Yes - name of case

Are they under investigation for COVID-19?
Result - PositiveResult - NegativeResult - Unknown
Personal Symptoms - from when?

Flu Like SymptomsSore ThroatCough?FeverShortness of BreathSelf Isolation - from when?


ElderlyDiabetesCancerOn Chemotherapy or immune suppressionCOPD/emphysemaRecurrent chest infectionAsthma

Family GP:

Family GP Name (required)

Family GP Contact (required)

Family* GP Adress (required)

Have you called NICD? If so indicate response below