COVID-19 Visitor Screening

Determine whether or not a visitor can enter the premise based on recent actions pertaining to COVID.

"*" indicates required fields

Step 1 of 9

Please enter your name*

First Name Last Name

Phone*

Email*

Are you fully vaccinated against COVID-19 and possess proof of vaccination?*

14 days or more must have elapsed since your final dose to be considered fully vaccinated.

Yes

Have you received a booster dose of the vaccine?*

This will be your third vaccination shot.

Yes

Have you tested positive for COVID-19 within the last 90 days?*

Select no if you have been medically cleared.

Yes

Have you travelled outside of Canada in the last 14 days and been instructed to quarantine per federal regulatation?*

Yes

Have you been instructed by a medical professional to isolate or stay at home?*

This can be due to an outbreak or contact tracing.

Yes

In the last 10 days, have you tested positive for COVID-19 with a rapid antigen test or home-based self-testing kit?*

You can select no if you have since tested negative with a lab-based PCR test.

Yes

Today's date is

When was the last time you were tested for COVID-19?

Please leave the field blank if you have never been tested for COVID-19.

MM slash DD slash YYYY

Are you currently experiencing any of the following symptoms*

Please choose any symptoms that are currently present and/or worsening that are not related to a previously known condition

Fever and/or chills

Coughing

Shortness of breath

Decrease/loss of taste or smell

Muscle aches/joint pain

Extreme Tiredness

None of the above

Dr Bob Kemp Hospice

277 Stone Church Road East
Hamilton, ON L9B 1B1

Funding for Dr. Bob Kemp Hospice is provided by Ontario Health West, grants, event fundraising and community donations.

Charitable Registration #134922392RR0001