Please complete the following form 24 hours prior to entering our hospital. *Note this form must be completed by the person attending the appointment.

  • MM slash DD slash YYYY
    Select any of the symptoms you have

  • COVID EXPOSURE ASSESSMENT

    Has a doctor, health provider or health unit told you you should be self-isolating?
    Have you been identified as a close contact of someone who currently has Covid-19 in the last 14 days?
    Have you received a COVID Alert exposure notification on your cell phone in the last 14 days (and have not been tested or are awaiting your result)?
    Have you or anyone you live with travelled outside of Canada in the last 14 days?
    Is anyone you live with experiencing any new COVID symptoms and/or waiting for COVID-19 test results after experiencing symptoms?

  • If the answer is YES to any of the questions on this form, PLEASE DO NOT ENTER this location AND contact your health provider, local health unit or Telehealth (1-866-797-0000) for assessment and to see if you need a COVID-19 test.

  • This field is for validation purposes and should be left unchanged.