First Name

Last Name

COVID Screening: Are you experiencing any of the following? COVID Screening: Are you experiencing any of the following? 1. Severe difficulty breathing (e.g. struggling to breathe or speaking in single words) 2. Severe chest pain 3. Having a very hard time waking up 4. Feeling confused 5. Losing consciousness NONE OF THE ABOVE

Are you experiencing any of the following? Are you experiencing any of the following? 1. Mild to moderate shortness of breath 2. Inability to lie down because of difficulty breathing 3. Chronic health conditions that you are having difficulty managing because of difficulty breathing NONE OF THE ABOVE

Are you experiencing cold, flu or COVID-19-like symptoms, even mild ones? Symptoms include: fever, chills, cough or worsening of chronic cough, shortness of breath, sore throat, runny nose, loss of sense of smell or taste, headache, fatigue, diarrhea, loss of appetite, nausea and vomiting, muscle aches? Are you experiencing cold, flu or COVID-19-like symptoms, even mild ones? Symptoms include: fever, chills, cough or worsening of chronic cough, shortness of breath, sore throat, runny nose, loss of sense of smell or taste, headache, fatigue, diarrhea, loss of appetite, nausea and vomiting, muscle aches? Yes No

Have you travelled to any countries outside Canada (including the United States) within the last 14 days? Have you travelled to any countries outside Canada (including the United States) within the last 14 days? Yes No

Did you provide care or have close contact with a person with confirmed COVID-19? Did you provide care or have close contact with a person with confirmed COVID-19? Yes No

In the last 10 days, have you been identified as a "close contact" of someone who currently has COVID-19 (confirmed by a PCR or rapid antigen test)? In the last 10 days, have you been identified as a "close contact" of someone who currently has COVID-19 (confirmed by a PCR or rapid antigen test)? Yes No

We are sorry but we cannot take your appointment at this time. Please contact the Front Desk to reschedule once a negative COVID-19 test has been produced. Thank you