COVID-19 Screener

Please complete the following COVID-19 Screening questionnaire prior to each appointment at the clinic. Please read carefully as our questions have changed as per the most recent guidelines.
Thank you for helping us limit the spread of COVID-19.

COVID-19 Screener

How are you feeling today?

Please complete on the SAME day as your appointment.

First Name

Last Name

Child's name (if applicable)

Select a date

I/My child does not have any of the following symptoms: fever and/or chills, new onset of cough or worsening chronic cough, shortness of breath, decrease of loss of sense of taste or smell, unexplaines fatigue/lethargy/muscle aches (myalgias), nausea/vomiting, diarrhea

I/My child have not tested positive for COVID-19 in the past 10 days and have not been asked to self-isolate.

I/My child has not travelled outside of Canada in the past 14 days.

I/My child has not had close contact with a confirmed case of COVID-19 without wearing appropriate PPE.

Thank you for helping us limit the spread of COVID-19.

Position

info@keytospeech.ca | 613-986-4218 | Unit 1 - 373 Vantage Drive, Orléans, ON K4A 3W2