Visitor Screening Form - Wilmot Veterinary Clinic

 519-696-3102 … Request an Appointment

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Please note: We will be closed Saturday, October 8th through Monday, October 10th in observance of Thanksgiving. For emergencies, please contact the Emergency Veterinary Clinic of Waterloo Region at 519-650-1617. Happy Thanksgiving!

Client Care Center

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. 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)? *

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

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)? *

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)? *

How many COVID vaccinations have you had?

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 *

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