COVID-19 screening - Dr. Amanda Lett - Chiropractor

First Name *

Last Name *

* Screening questions based on the most recent Ministry of Health COVID-19 Patient Screening Guidance Document

Have you received your final (or second) COVID-19 vaccination dose more than 14 days ago? *

NoYesNo

Are you currently experiencing any of the following symptoms ( Fever and or chills, New onset of cough or worsening chronic cough, shortness of breath, decrease or loss of taste or sense of smell, adults( unexplained lethargy, malaise, fatigue or myalgia), children (nausea, vomiting, diarrhea), *

Have you or anyone in your household tested positive for COVID-19 in the past 10 days or have you been told you should be isolating? *

NoYesNo

Have you traveled outside of Canada in the past 14 days? *

NoYesNo

Have you had close contact with a case of COVID-19 without wearing appropriate PPE? *

NoYesNo

I certify the information above is complete and accurate. I acknowledge that the information on this form will be kept securely stored and encrypted on Colib website, viewable by the organization I plan to visit.

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COVID-19 screening - Dr. Amanda Lett - Chiropractor

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The information has been received.

Did you enjoy the Colib experience?

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* Screening questions based on the most recent Ministry of Health COVID-19 Patient Screening Guidance Document

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