COVID Screening Appointment Check in

COVID Screening Appointment Check in
This form is to be completed 24 hours in advance of a scheduled Appointment
Name *

First Name Last Name
Date of Appointment *

Month Day Year
Date
Current Address *
Phone Number to contact during the appointment *
Please enter a valid phone number.
Make, Model and Colour of the vehicle you will be arriving in: *
Pets name: *
Preferred Payment Method *

Debit/Interac Credit (Visa/Mastercard/Amex) Cash
Email Address *
Do you have any of the following new or worsening signs or symptoms? *

Fever or Chills (tempurature of 37.8C or higher) Coughing or barking cough Severe Shorteness of breath Decreased smell or loss of taste Muscle/Joint aches Extreme tiredness Sore throat Runny or stuffy nose Headache Nausea, vomiting or Diarrhea None of the Above
Is anyone you live with currently experiencing any new COVID 19 symptoms? *

Yes No
Is anyone you live with currently isolating due to COVID-19 Symptoms? *

Yes No
Is anyone you live with currently waiting for test results after experiencing symptoms? *

Yes No
In the last 14 days, have you travelled outside of Canada and been told to quarantine (per federal quarantine requirements)? *

Yes No
In the last 10 days have you been identified as a close contact of someone who currently has Covid-19? *

Yes No
Has a doctor, healthcare provider, or public health unit told you that you should currently be isolating (staying at home)? (Due to outbreak or contact tracing.) *

Yes No
In the last 10 days, have you tested positive for COVID 19? *

Yes No
Communication Preference

Phone Email Text
Signature *

Clear
Results of Screening Questions:
- If you have answered NO to all questions , you may bring your pet for their appointment. Please remember to wear a mask when engaging with staff members. We ask that you kindly follow the Covid-19 protocol outlined in the attachment on this email.
- If you have answered YES to any questions , you are advised to go home to self-isolate and contact your health care provider or Telehealth (1-866-797-0000) to find out if you need a COVID-19 test.
Should be Empty:

COVID Screening Appointment Check in

This form is to be completed 24 hours in advance of a scheduled Appointment