Concerned that you have contracted the COVID19 virus?

Please complete the form below or mail us on info@evamed.co.za

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?

Comorbidity

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

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