Coronavirus triage questionnaire

Please fill out the questions below and submit them to ISISPACE when making an appointment or coming to our offices in Delft:

Date:

Did you have one or more of the following symptoms in the past 24 hours?

yesno

Does someone in your household have a fever and/or shortness of breath?
yesno

According to the latest Dutch government guidance (see: https://quarantainecheck.rijksoverheid.nl/en), do you need to be currently in quarantine?
yesno

I consent to have this website store my submitted information, in accordance with the Privacy Policy.

If you answered yes to one or more of these questions, you are not allowed to come to our offices in Delft, do not make an appointment, or cancel your appointment. We will gladly receive you in the future when you can answer all questions with "No".