Patient Screening

Q3. Have you travelled outside of Canada in the past 14 days? *

Yes

No

Scheduled date of the appointment: *

Q1. Do you have any of the following symptoms: *

Fever and/or chills

New onset of cough or worsening chronic cough

Shortness of breath

Decrease or loss of sense of taste or smell

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

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

NO SYMPTOMS

Accompanying person's full name (if applicable):

Q2. Have you tested positive for COVID-19 in the past 10 days or have you been told you should be isolating? *

Yes

No

Q4. Have you had close contact with a confirmed case of COVID-19 without wearing appropriate PPE? *

Yes

No

Q5. Did you receive your final (or second) vaccination dose more than 14 days ago? *

Yes

No

Patient's full name: *