Form 3B - *COMPLETE ON THE DAY OF THE APPOINTMENT*

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Use this form to screen patients on the day of their appointment.

Email *

Patient Name: *

Do you have a fever or have felt hot or feverish anytime in the last two weeks? *

Yes

Do you have any of these symptoms: Dry cough? Shortness of breath? Difficulty breathing? Sore throat? Runny nose? *

Yes

Have you experienced a recent loss of smell or taste? *

Yes

Have you been in contact with any confirmed COVID-19 positive patients, or persons self-isolating because of a determined risk for COVID-19? *

Yes

Have you returned from travel outside of Canada in the last 14 days? *

Yes

Have you returned from travel within Canada from a location known affected with COVID-19? *

Yes

Are you over the age of 60? *

Yes

Do you have any of the following? Heart disease, lung disease, kidney disease, diabetes or any auto-immune disorder? *

Yes

What is your temperature? (°C) *

A copy of your responses will be emailed to the address you provided.

Submit

Clear form

Never submit passwords through Google Forms.

reCAPTCHA

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy