Coronavirus Self-Declaration Form
For the health and safety of our community, a declaration of illness is required. Please make sure that the information you give is accurate and complete. Thank you for your cooperation.
Email Address
example@example.com
Full Name
First Name
Last Name
Date of Appointment
-
Month
-
Day
Year
Date
Have you travelled outside of Canada within the last 14 days?
Yes
No
Have you been in contact with a person that is infected, suspected or diagnosed with Covid-19?
Yes
No
IF YOU ANSWERED YES IN THE PREVIOUS QUESTION: What is your relationship with the person and when was your last contact date with them?
Please check the box if you are experiencing or have experienced these symptoms in the past 7 days.
Fever
Dry Cough
Tiredness
Runny Nose
Difficulty breathing or shortness of breath
Chest pain or pressure
Loss of speech or movement
Aches and pains
Sore throat
Diarrhea
Conjunctivitis
Headache
Loss of taste or smell
A rash on skin, or discolouration of fingers or toes
Not applicable
Note:
If you have checked any of the boxes in the above-mentioned question we will ask you to reschedule your appointment to at least 14 days after today's date.
I certify that the above information is accurate. Add your initial.
Submit
Should be Empty: