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
Submit
Should be Empty: