COVID-19 Patient Screening Form
Email address *
Patient Name *
Date *
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DD
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YYYY
1. Has the patient travelled outside Canada in the past 14 days? *
2. Does the patient have a confirmed case of COVID-19 or had close contact with a confirmed case of Covid-19 without wearing appropriate PPE? *
3. Does the patient have any of the following symptoms?
4. If you are 70 years of age or older, are you experiencing any of the following symptoms?
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