Health Screening Questionnaire

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To prevent the further spread of COVID-19, and reduce the potential risk of exposure to clients, employees and business partners, we are conducting a simple screening questionnaire prior to your scheduled appointment. Your participation is important to ensure the safety and well being of everyone.

电子邮件地址 *

Have you had close contact with or cared for someone exposed with COVID-19 within the last 14 days? *

Have you experienced flu-like symptom (to include fever, cough, sore throat, difficulty in breathing or diarrhea) within the last 14 days? *

Have you been hospitalized or visit any medical facility within the last 20 days? *

Have you been in closed contact with anyone who has travelled abroad within the last 14 days? *

Full Name *

Residential Address *

Mobile Number *

Purpose of Visit *

Contact Person *

Gateway to Canada Staff you have appointment with

Appointment Date *

年

月

日

Appointment Time *

时间

Declaration *

By checking this box and submitting this form, I declare under penalty of perjury under the laws of the Philippines that the foregoing is true and correct.

必填

您回复的副本将通过电子邮件发送到您提供的地址。

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