Visitor Screening Form - 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. In the last 10 days, has someone you live with been sick with symptoms associated with COVID-19 and/or tested positive for COVID-19 (on a rapid antigen test or PCR test)?

Yes
No

3. In the last 10 days, have you tested positive on a rapid antigen test or home-based self-testing kit?

Yes
No

4. In the last 10 days, have you been identified as a “close contact” of someone who currently has COVID-19 (confirmed by a PCR or rapid antigen test)?

Yes
No

5. In the last 14 days, has someone in your household (someone you live with) travelled outside of Canada AND been advised to quarantine (as per the federal quarantine requirements)?

Yes
No

How many COVID vaccinations have you had?

0
1
2
3

If you answered yes to any of the following questions please call us and remain outside or in your vehicle for further instructions.

Signature

Date

COVID-19 Screening Questionnaire

Appointment