Please complete our COVID-19 pre-screening form

Patient First & Last Name



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Did the person receive their final (or second) vaccination dose more than 14 days ago?

Yes, patient is fully vaccinated

No


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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


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If an adult > 18 years of age: Is the person experiencing unexplained fatigue / lethargy / malaise / muscle aches (myalgias)

Yes

No


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If child < 18 years of age: Is the person experiencing nausea/vomiting, diarrhea

Yes

No


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Has the person tested positive for COVID-19 in the past 10 days or have they been told they should be isolating?

Yes

No


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(Skip this question if the person is fully vaccinated) Did the person travel outside of Canada in the past 14 days?

Yes

No


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(Skip this question if the person is fully vaccinated) Has the person had close contact with a confirmed case of COVID-19 without wearing appropriate PPE?

Yes

No


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I verify the information I have provided on this form is truthful and accurate.

I Agree


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