Mandatory Covid 19 Exposure Survey

In according with AHS requirement, every client should fill

Only clients who answer "NO" will be able to proceed with their appointments.

If you answered "Yes" to one of the questions, please do not come to the clinic and contact us, so we can reschedule your appointment

Question Title

* 1. Have you been tested positive for Corona Virus in the last two weeks?

Yes

No

Question Title

* 2. Have you been in contact with someone tested positive for Covid 19 in the last two weeks?

Yes

No

Question Title

* 3. Have you experienced or been in contact with someone with flu-like symptoms in the last two weeks?

Yes

No

Question Title

* 4. Have you traveled outside Canada in the last two weeks?

Yes

No

Question Title

* 5. If you answered "NO" to all your questions please fill your contact info

First Name

Last Name

Email Address

Phone Number

Question Title

* 6. Your Appoint Date and time

Date / Time

Date

Time

AM/PM