Please complete our COVID-19 pre-screening form
Patient First & Last Name
Next >
Did the person receive their final (or second) vaccination dose more than 14 days ago?
Yes, patient is fully vaccinated
No
< Prev
Next >
Does the person have any of the following symptoms:
. Fever and/or chills
. New onset of cough or worsening chronic cough
. Shortness of breath
. Decrease or loss of sense of taste or smell
Yes
No
< Prev
Next >
If an adult > 18 years of age: Is the person experiencing unexplained fatigue / lethargy / malaise / muscle aches (myalgias)
Yes
No
< Prev
Next >
If child < 18 years of age: Is the person experiencing nausea/vomiting, diarrhea
Yes
No
< Prev
Next >
Has the person tested positive for COVID-19 in the past 10 days or have they been told they should be isolating?
Yes
No
< Prev
Next >
Did the person travel outside of Canada in the past 14 days?
Yes
No
< Prev
Next >
Has the person had close contact with a confirmed case of COVID-19 without wearing appropriate PPE?
Yes
No
< Prev
Next >
Confirm your email address:
< Prev
(Please click submit only once)