COVID-19 Self Assessment Tool
We ask that for your safety and the safety of our clients, staff and clinical space, that you please fill out this form to the best of your ability, no more than 24 hours prior to attending your appointment.

Please be honest - by answering "Yes" to any of the questions, does not automatically prevent you from attending your scheduled appointment.

We thank you for your time and attention to this self-assessment tool.
Last Name *
First Name *
If you have answered YES to any of the questions, or are experiencing any symptoms, we ask that you please contact the office at 306-933-3372 for further discussion.
Do you have any of the following - click all that apply *
Required
Were you exposed to someone who is under investigation for COVID-19 or has been confirmed as having COVID-19 within the last 14 days? *
In the past 14 days have you returned from or been exposed to someone who has returned from any international travel? *
In the past 14 days have you returned from or been exposed to someone who has returned from any out of province travel? Please note, that by answering YES, it does not prevent you from attending your scheduled appointment, rather as per the government recommendations, we ask that you please closely self monitor for any symptoms. *
Has anyone in your household been instructed to self-isolate within the last 14 days? *
Have you been in a community with a known COVID-19 outbreak within the last 14 days? *
If you have answered YES to any of the questions, or are experiencing any symptoms, we ask that you please contact the office at 306-933-3372 for further discussion.
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