Question Title

* 1. First & Last Name 

Question Title

* 2. Have you had close contact with anyone with acute respiratory illness or travelled outside of Ontario in the past 14 days?

Question Title

* 3. Have you had a confirmed case of COVID-19 or had close contact with someone with a confirmed case?

Question Title

* 4. Do you have any of the following?

Question Title

* 5. Are you 70 years or older and experiencing any of the following symptoms?

Question Title

* 6. Your submission also indicates that you accept the inherent risks of non- complying with clinic policies in light of the COVID-19 pandemic and any potential exposure that occurs as a result. 

0 of 6 answered
 

T