Complete Wellness Clinic - COVID Screening
Please fill out this quick survey prior to your visit to help everyone stay safe and healthy.
Please note these questions have changed to reflect the guidelines mandated by Health Ontario and our professional colleges. Thank you for your understanding.
Sign in to Google to save your progress. Learn more
Email *
Patient Name *
Appointment Date *
MM
/
DD
/
YYYY
Have you received your final vaccine and are fully vaccinated? *
Required
Please note at this time we are required and mandated by our professional colleges to enquire about vaccine status. Please note the answer to this question alone does not determine your eligibility for your appointment.
Do you have any of the following symptoms? (Check all that apply) *
Required
Have you tested positive for COVID-19 in the past 10 days? *
Have you or any members of your household been told to isolate or are currently under quarantine? *
Have you travelled outside Canada in the past 14 days? *
Have you had close contact with a confirmed case of COVID-19 without wearing appropriate PPE? *
If you have answered "NO" to ALL of the questions regarding covid testing, quarantine and DO NOT exhibit any of the listed symptoms then you may proceed with your appointment.
If you have answered "YES" to any questions regarding covid testing, quarantine or any symptoms please call the clinic. You may be asked to reschedule your appointment and further questioning may be required.
By typing your name below, you certify all information is true and correct to the best of your knowledge. *
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy