Visitor Screening Form - Wilmot Veterinary Clinic

519-696-3102 wvc@rogers.com

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COVID-19 Screening Questionnaire

Please complete this Visitor Screening Form just prior to entering Wilmot Veterinary Clinic

Visitor Name: *

Visitor Contact Number: *

1. Are you exhibiting any of the following symptoms? (please check all that apply) *

Fever or chills
Difficulty breathing or shortness of breath
Cough
Sore throat, trouble swallowing
Runny nose/stuffy nose or nasal congestion
Decrease or loss of smell or taste
Nausea, vomiting, diarrhea, abdominal pain
Not feeling well, extreme tiredness, sore muscles
None of the above

2. Have you travelled outside of Canada in the past 14 days? *

Yes
No

3. Have you had close contact with a confirmed or probable case of COVID-19? *

Yes
No

How many COVID vaccinations have you had?

0
1
2

Signature *

Date *

Message

Appointment