Covid Screening – River Road Animal Hospital

Name*

First Last

Date*

Phone*

Do you have any of the following new or worsening symptoms or signs? Symptoms should not be chronic or related to other known causes or conditions.

Fever
Cough
Shortness of breath
Sore throat
Chills
Muscle Aches
Loss of taste or smell
Runny nose

Have you come in contact with anyone who tested positive for COVID in the last 30 days?

Yes
No

Have you come in contact with anyone currently waiting for test results in the last 30 days?

Yes
No

Have you come in contact with anyone that has been asked to quarantine or been exposed to a person who is a confirmed positive case for COVID in the last 30 days?

Yes
No

Have you or anyone you've come in contact with travelled outside of Canada in the last 30 days?

Yes
No

Are you fully vaccinated and able to provide proof?

Yes
No