Mandatory COVID-19 Pre-Screening
Please fill out this form within 24 hours of your visit. These information could also be used for contact tracing purposes, should Ottawa Public Health require them.
Full Name
*
First Name
Last Name
Email
*
example@example.com
Date of your visit:
*
-
Month
-
Day
Year
Client Screening
Do you have any of the following new or worsening symptoms or signs?
*
New or worsening cough
Fever
Sore throat
Runny nose, sneezing or nasal congestion (not seasonal allergies)
Difficulty swallowing
Nausea/vomiting
Headache
Chills
Unexplained fatigue/malaise
No, I do not have any of these symptoms.
Have you had close contact with anyone who tested positive with COVID-19?
*
Yes
No
I agree to wear a CLEAN mask to my appointment (no exceptions):
*
Yes
No
I agree to use hand sanitizer or wash my hands upon arrival:
*
Yes
No
*
I hereby declare that the information provided is true and correct. I, also agree, that the information above may be shared with Ottawa Public Health, solely for the purpose of contact tracing.
Signature:
*
Clear
Date:
*
-
Month
-
Day
Year
Submit
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