Name

First Name

Last Name

Are you aware you are COVID-19 positive or are you waiting for a test result? *

Yes (You cannot visit the clinic)

No

Do you have a fever or have felt hot or feverish anytime in the last two weeks (14 days)? *

Yes (You cannot visit the clinic)

No

Do you have any of the following symptoms: Dry cough? Shortness of breath? Difficulty breathing? Sore throat? Runny nose? Post-nasal drip? *

Yes (You cannot visit the clinic)

No

Have you experienced a recent loss of smell or taste? *

Yes (You cannot visit the clinic)

No

Have you been in contact with any confirmed COVID-19 positive patients, or persons self-isolating because of a determined risk for COVID-19? *

Yes (You cannot visit the clinic)

No

Have you returned from travel outside of BC in the last 14 days? *

Yes (You cannot visit the clinic)

No