COVID Screening Form

COVID SCREENING FORM

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

  • 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.