Complete the form and we will send you a confirmation to your emailPatient Screening FormPlease enable JavaScript in your browser to complete this form.Full Name *Email *1- Do you have a concern for a potential COVID-19 infection (e.g. is there an outbreak in the facility, is the patient awaiting COVID-19 test results, etc)? *YesNo2- Did the person travel outside of Canada or Province in the past 14 days? *YesNo3- Have you tested positive for COVID-19 or had close contact with a confirmed case of COVID-19 without wearing appropriate PPE? *YesNo4- Do you have any of the following symptoms? *YesNoFever New onset of cough Worsening chronic cough Shortness of breath Sore throat Unexplained fatigue/malaise/muscle aches (myalgias) Runny nose or nasal congestion without other known causeSubmitScreening Form
