COVID-19 Screening Form

Name*

First Last

Email*

Are you experiencing any Cold or Flu like symptoms? Specifically a new or worsening Cough or Fever?*

No
Yes

Comments:

If you answered YES, to any of the above symptoms you are not allowed to enter the clinic at this time. As per Nova Scotia Public Health Regulations, you should self-isolate at home, and call 811

Have you been outside Nova Scotia in the past 7 days? (Double Vaccination Exemption)*

No
Yes

Have you been at a potential exposure site? Been in contact with someone who has? Or are awaiting a COVID test result?*

No
Yes

If you answered YES, to any of the above then you may not be allowed to enter the clinic at this time. We can book you for a TeleHealth appointment or we can reschedule you for 2 weeks from now. It is recommended you go to https://novascotia.ca/coronavirus/when-to-seek-help/ for more information on when to seek help/call 811

Consent*

I accept

I confirm that the information given in this form is true, complete and accurate

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