Health Screening Questionnaire
To prevent the further spread of COVID-19, and reduce the potential risk of exposure to clients, employees and business partners, we are conducting a simple screening questionnaire prior to your scheduled appointment. Your participation is important to ensure the safety and well being of everyone.
Email address *
Have you had close contact with or cared for someone exposed with COVID-19? *
Have you experienced flu-like symptom (to include fever, cough, sore throat, difficulty in breathing or diarrhea)? *
Have you been hospitalized or visit any medical facility within the last 20 days? *
Have you been in closed contact with anyone who has travelled abroad within the last 14 days? *
Full Name *
Residential Address *
Mobile Number *
Purpose of Visit *
Contact Person *
Gateway to Canada Staff you have appointment with
Appointment Date *
MM
/
DD
/
YYYY
Appointment Time *
Time
:
Declaration *
Required
A copy of your responses will be emailed to the address you provided.
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