Local: (905) 218-6556 | 341 Beach Blvd, Hamilton, ON
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Ontario Ministry of Health COVID-19 Patient Screening Form
To be completed ON THE DAY OF YOUR APPOINTMENT only
Please only complete the Ontario Ministry of Health Patient COVID-19 screening ON THE DAY OF YOUR APPOINTMENT. Unfortunately, we are unable to accept screening questionnaires completed the evening before your appointment. We are sorry for the inconvenience.
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Have you received your final (or second) vaccination dose more than 14 days ago?
Have you travelled outside of Canada in the last 14 days?
Have you had close contact with a confirmed case of COVID-19 without wearing appropriate PPE?
Have you tested positive for COVID-19 in the past 10 days or have you been told you should be isolating?
COVID-19 Symptom Screening (please check any that apply)
Fever and/or chills
New onset of cough or worsening chronic cough
Shortness of breath
Decrease or loss of sense of taste or smell
If an adult >18 years of age: unexplained fatigue/lethargy/malaise/muscle aches
If a child <18 years of age: nausea/vomiting, diarrhea
I DO NOT have any COVID-19 symptoms or risk factors
If you do not have any COVID-19 symptoms please confirm this by checking the negative screening statement below.
NEGATIVE SCREENING STATEMENT
I confirm that I have reviewed the COVID-19 symptoms carefully and none apply to me.