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Pre-Appointment COVID-19 Screening Questions
You must complete and submit this questionnaire BEFORE your appointment. Only essential people (e.g translator, advocate) may also attend the appointment with you; they must also complete the screening questions separately.
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Indicates required field
Name
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First
Last
Phone Number
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Email
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Are you experiencing cold, flu or COVID-19-like symptoms, even mild ones? Symptoms include: fever, chills, cough, shortness of breath, sore throat and painful swallowing, stuffy or runny nose, loss of sense of smell, headache, muscle aches, fatigue or loss of appetite.
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No
Yes
Have you travelled to any countries outside Canada, including the USA, within the last 14 days?
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No
Yes
Did you provide care or have close contact with a person with confirmed COVID-19? Note: This means you would have been contacted by your health authority’s public health team.
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No
Yes
Submit