COVID-19 Visitor Screening - Dr. Bob Kemp Hospice

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

No

Have you received a booster dose of the vaccine?*

This will be your third vaccination shot.

Yes

No

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

Select no if you have been medically cleared.

Yes

No

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

Yes

No

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

No

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

No

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.

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

Name

This field is for validation purposes and should be left unchanged.