Covid-19 Screening Questionnaire

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Screening Tool

Email *

Have you submitted your Vaccine Certificate with QR code for scanning (mandatory as of January 4, 2022)? If no you can email a PDF copy prior to your appointment. *

yes

I have emailed my QR code

Please add your full name: *

Do you have any of the following new or worsening symptoms or signs? Symptoms should not be chronic or related to other known causes or conditions. *

yes

Fever or chills

Difficulty breathing or shortness of breath

Cough

Sore throat, trouble swallowing

Runny/stuffy nose or nasal congestion

Decrease or loss of smell or taste

Nausea, vomiting, diarrhea, abdominal pain

Not feeling well, extreme tiredness, sore muscles

Have you travelled outside Canada in the past 14 days

Have you had close contact with a confirmed or probable case of Covid-19

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