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Clergy Street Family Physicians COVID-19 Screening

This is to be completed by patients who already have an appointment booked.

 

* Caregivers / Parents, please complete a separate form

 

Please tell us your email address.

Please tell us your health card version code.

Please tell us your first name.

Please tell us your last name.

Please tell us your date of birth.

Please tell us the reason for your appointment.

Have you been tested for COVID-19 within the last 14 days?

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Do you have a fever?

 

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Have you travelled outside of Canada?

 

In the last 14 days have you had close, unprotected contact?

 

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Thank you for completing the COVID-19 Screening questions

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Saturday & Sunday:  8:15 am - 10:30 am

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