Referral to Medical Practitional

The following person has failed our screening process and is therefore being referred to a medical practitioner for a medical diagnosis.

First name *

Last name *

Phone *

Screening Date *

Please note that actions to prevent the spread of the COVID-19 (COV-2) virus has been implemented into our office protocols, therefore we request to be notified of the above mentioned individual's test results via the following contact method: Please mail: covid19@copperfibreafrica.co.za

IMPORTANT: Before you will be allowed to return to work, you will be required to obtain a letter from your medical practitioner giving you a diagnosis other than COVID-19 and/or a test certificate showing a NEGATIVE outcome.

I agree with the privacy policy and confirm that my personal information may be used in accordance with the law *

* required fields