COVID-19 Questionnaire – Veterinarians Stratford

Date*

Date Format: MM slash DD slash YYYY

Name*

First Last

Phone*

Email

Pet Name*

Have you or anyone in your household traveled outside of Canada in the last 14 days?*

Do you have a confirmed case of COVID-19 or had close contact with a confirmed case of COVID-19 without wearing appropriate PPE?*

Do you have any of the following symptoms? (check all that apply)*

If you answered yes or checked off any symptoms you must speak with someone in the office prior to arrival. Please refer to the Ontario self assessment guide for COVID-19, contact your physician or Telehealth (1-866-797-0000).

I understand that the facility has performed all reasonable steps outlined by the Ministry of Health for my protection.*