Please Carefully read and answer ALL following questions:

1 – Did you receive your final (or second) vaccination dose more than 14 days ago?
You Answered NO.

2 – Have you travelled outside of Canada in the past 14 days?
YesNo

3- Have you come in contact with a confirmed case of COVID-19 in the past 14 days without wearing appropriate PPE?
YesNo

4- Do you currently have ANY of the following symptoms?
Fever (of 38C / 100.4F or higher) and/or chills?
YesNo

New onset of cough or worsening chronic cough?
YesNo

Shortness of Breath?
YesNo

Decrease or loss of sense of taste or smell?
YesNo

5- Adults over 18 years of age (Any unexplained fatigue, joint pain or muscle ache) or Child under 18 years of age (Any nausea, vomiting or diarrhea)?
YesNo

6- Have you tested positive for COVID-19 in the past 10 days or have you been told to isolate?
YesNo

If you answer “YES” to any of above question, we ask that you immediately contact the clinic at 905-237-7174 to discuss appropriate next steps and in-person appointments alternatives.

Declaration:
I have answered all the above questions honestly and truthfully

Signature