Ask Nereda First COVID-19 Screening Form
Thank you for booking an appointment with us! We require anyone booking an in-office appointment to complete this screening form the day before their appointment. If you have any questions, please contact us at 226-432-2332, or by email at info@askneredafirst.com.

Our COVID-19 Policy can be viewed at https://www.askneredafirst.com/covid-19-policy
Name *
Contact Information (Phone # or Email address) *
Address *
Have you travelled outside of Ontario in the last 14 days? *
Are you experiencing any symptoms of COVID-19 (e.g., shortness of breath, cough, sore throat, or fever)? *
Have you been in close contact with a person showing symptoms or tested positive for COVID-19? *
Have you been in close contact with a person who has been outside of Canada in the last 14 days? *
Do you live in, work in, or visit the Windsor-Essex region that will remain in Stage 2 after July 31st? *
Thank you for completing the screening form. We will be in touch if there are any follow-up questions. We look forward to seeing you at your appointment!
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