COVID-19 Client Screening

COVID-19 Client Screening

Please continue to support your local small businesses by truthfully inputing and completing all the COVID-19 questions within the screening form. With that being said, also please reschedule your appointment if you are feeling unwell to help keep everyone safe!
Name

First Name Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Are you currently experiencing any of the following:

New or worsening cough Shortness of breath Fever/chills Difficulty swallowing Nasal congestion Loss of taste or smell Headaches Muscle/joint pain Nausea, vomiting, diarrhea Extreme fatigue NONE OF THE ABOVE
Have you travelled outside of Canada in the last 14 days?

Yes No
Is anyone you live with currently experiencing any of the symptoms listed above?

Yes No
Is anyone you've come into contact with in the last 14 days waiting for a COVID-19 test result?

Yes No
Have you come into contact with anyone who is COVID-19 positive in the last 14 days?

Yes No
Should be Empty:

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