Customer Appointments On Site

Full Name

Mobile

Email

Postcode

Lot Address

Appointment type

Appointment reason

In the last 30 days, have you had any of the following symptoms?

Fever

Yes

No

Chills or sweats

Yes

No

Sore throat

Yes

No

Runny nose

Yes

No

Nausea

Yes

No

Fatigue

Yes

No

Shortness of breath

Yes

No

Loss of sense of smell

Yes

No

Have you returned from overseas travel in the past 30 days?

Yes

No

Have you had a test for Coronavirus without a negative outcome?

Yes

No

Have you had any known close contact with anyone who would answer yes to the above questions?

Yes

No

I understand that this information will be handled in accordance with Orbit Homes’ privacy policy and it will be supplied to the government if required for COVID-19 contact tracing purposes. in-line with the Victorian Government’s COVID-19 restrictions, I accept these terms and declare the truthfulness of the statements above.

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Customer Appointments On Site