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COVID Pre-screening form

This form must be completed within 24 hours of your appointment. If you have any yes answers, please provide details in the space provided. Someone from the office will call and follow up if your appointment needs to be rescheduled.

Thank you for doing your part to keep all of us safe.

    Mandatory Screening Questions

    1. Do you have a fever or have felt hot or feverish anytime in the last two weeks? *

    2. Do you have any of these symptoms: *

    Dry cough? Shortness of breath? Difficulty breathing? Sore throat? Runny nose?
    Sneezing? Post-nasal drip? Muscle Aches? Headache? Nausea? Vomiting?
    Diarrhea? Malaise?

    3. Have you experienced a recent loss of smell or taste? *

    4. Have you been in contact with any confirmed COVID-19 positive patients, or persons self-isolating because of a determined risk for COVID-19? *

    5. Have you returned from travel outside of Canada in the last 14 days? *

    6. Have you returned from travel within Canada from another province or a location known to be affected with COVID-19? *

    7. Is your workplace considered high risk? *

    8. Have you attended or participated in a mass gathering (ie: protest or demonstration) in the past 2 weeks? *

    Please provide details for any ‘Yes’ answers