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Are you a current or new patient?*
Patient Name*
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Question 1: Did you receive your final (or second) vaccination dose more than 14 days ago?*
* A fully immunized individual is defined as any individual >14 days after receiving their second dose of a two-dose COVID-19 vaccine series or their first dose of a one-dose COVID-19 vaccine series (i.e .Johnson and Johnson).
Question 2: Do you have any of the following symptoms?*
Question 3:Have you tested positive for COVID-19 in the past 10 days or have you been told you should be isolating?
Question 4: Have you travelled outside of Canada in the past 14 days?
Question 5: Have you had close contact with a confirmed case of COVID-19 without wearing appropriate PPE?
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