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COVID-19 Questionnaire
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?
*
Yes
No
Do you have a confirmed case of COVID-19 or had close contact with a confirmed case of COVID-19 without wearing appropriate PPE?
*
Yes
No
Do you have any of the following symptoms? (check all that apply)
*
Fever
New Onset of Cough
Worsening Chronic Cough
Shortness of Breath
Difficulty Breathing
Sore Throat
Difficulty Swallowing
Decrease or Loss of Sense of Taste or Smell
Chills
Headache
Unexplained Fatigue/Malaise/Muscle Aches (Myalgias)
Nausea/Vomiting, Diarrhea, Abdominal Pain
Pink Eye
Runny Nose/Nasal Congestion Without Other Known Cause (Example of allergies or post nasal drip)
No Symptoms
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.
*
Yes
No
New Clients
What to Expect
Take A Tour
Hospital Policies
About Us
Location & Hours
Team
Events
Our Photos
FAQs
Career Opportunities
Companion Animal
Wellness Care
Preventive Services
Medical Services
Surgical Services
Grooming
Acupuncture
Nutritional Counseling
Additional Services
Health Care Plans
Health
Blog
Pet Health Articles
Pet Health Checker
How-To Videos
News
Links
Pet Portal