Patient Pre-Screening Form

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Please fill in this form at least 1 week - 48 hours prior to your appointment.

Patient Name: *

Patient Age: *

1) Have you had a final / second vaccination dose more than 14 days ago? *

Yes

If answer to question #1 is no, did you travel outside of Canada in the past 14 days?

Yes

Selectie wissen

If answer to question #1 is no, have you had close contact with a confirmed case of Covid-19 without wearing proper personal protective equipment (PPE)?

Yes

Selectie wissen

Do you have any of the following symptoms: *

Fever and / or chills

New onset of cough or worsening chronic cough

Shortness of breath

Difficulty breathing

Decrease or loss of sense of taste or smell

If adult > 18 years of age: Unexplained fatigue / malaise/ muscle aches (myalgias)

If child <18 years of age: Nausea/vomiting, diarrhea

NONE OF THE ABOVE

Verplicht

Have you tested positive for Covid-19 in the past 10 days or have been told to self isolate? *

Yes

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