1231 Appleby Line, Burlington
289-919-1231
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COVID-19 Screening Questionnaire
(To be completed by any individual (employee, volunteer, client, etc.) entering the practice. Screening should occur before or when a worker enters the practice at the beginning of their day or shift, and before a client or other visitor is admitted inside the practice.)
Staff/Visitor Name:
*
First
Last
Visitor Contact Number:
*
1. Are you exhibiting any of the following symptoms? (please check off all symptoms that you have been experiencing)
*
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
I am not experiencing any of the above symptoms.
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
Signature
*
Date
*
Date Format: MM slash DD slash YYYY
Results of Screening Questions:
-If the individual answers NO to all questions, they have passed and can enter the workplace.
-If the individual answers YES to any question, they have not passed and should be advised that they should not enter the workplace (including any outdoor, or partially outdoor workplaces). They should go home to self-isolate and contact their health care provider or Telehealth Ontario (1-866-797-0000) to find out if they need a COVID-19 test.
New Clients
What to Expect
Take A Tour
Make An Appointment
About Us
Our Hospital
Location & Hours
Payment Options
Careers
COVID-19 Update
COVID-19 Screening Questionnaire
Services
Wellness and Vaccination Programs
Preventive Services
Nutritional Counseling
Medical Services
Surgical Services
Anesthesia and Patient Monitoring
Health Screening Tests
Breeding Services
Emergency and/or Extended Care
Additional Services
Pet Health
Pet Health Library
How-To Videos
Pet Health Checker
Pet Insurance
News
Links
Beattie Blog
My Pet
Pet Records Signup
Pet Records Sign in
Appointment Request