COVID-19 Screening Form

Please fill out this form as completely and accurately as possible so we can get to know you and your pet(s) before your visit.

Name *

First

Last

Contact Number *

Pet's Name *

Appointment Date / Time *

Date

Time

Are you fully vaccinated against COVID-19? *

In the last 14 days, have you travelled outside of Canada? *

Are you or anyone you know and have been in contact with recently awaiting a COVID-19 test result? *

Do you live with anyone who is currently experiencing COVID-19 symptoms or is isolating due to a positive COVID-19 test result? *

Has a doctor, health care provider or public health unit told you that you should currently be isolating (staying at home)? *

In the last 5 days, have you tested positive on a rapid antigen test or home-based self testing kit? *

COVID-19Screening Form