Covid-19 Client Questionnaire

Covid-19 Client Questionnaireadmin2021-04-21T20:01:03-07:00

All clients who wish to enter the clinic must complete this form, wear a mask and sanitize their hands upon entering and exiting the building. We also ask that our clients stand in our designated areas unless otherwise asked to move.

Masks must be worn at all times

Please complete the following questionnaire - If you answer yes to any of the questions you will not be allowed to enter the clinic.

Specific Symptoms

Have you or a member of your household experienced any of the following symptoms within the last 14 days:

Fever *YesNo

Difficulty breathing *YesNo

New or worsening cough *YesNo

Shortness of breath *YesNo

Sore throat *YesNo

Diarrhea *YesNo

Loss of appetite *YesNo

Headache *YesNo

Chills *YesNo

Nausea or vomiting *YesNo

Loss of sense of smell or taste *YesNo

Headache *YesNo

General Questions

Have you or a member of your household travelled within Canada in the last 14 days? *YesNo

Have you or a member of your household returned from international travel within the last 14 days? *YesNo

Are you awaiting results for a Covid-19 test? *YesNo

Have you or a member of your household been in close contact with a person with confirmed covid-19? *YesNo

Have you been told to self-isolate by public health? *YesNo

Visitor Information

First Name *

Last Name *

Phone Number *

Date *

Email Address *

Please do not fill in this field.

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Little Paws Clinic
#130-12011 2nd Ave
Richmond, BC , V7E 3L6
Canada

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