Pre-appointment COVID-19 Screening

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.

* Indicates required field

Name *

First

Last

Phone Number *

Email *

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. *

Have you travelled to any countries outside Canada, including the USA, within the last 14 days? *

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. *

Submit