COVID-19 Health ScreeningInstructions In order to ensure the health and safety of our staff, clients, and community, it is important that all those planning on coming in for an in-person appointment go through screening steps to ensure they are appropriate for in-person appointments at this time. We ask that before every in-person appointment clients please fill out the following form. This form should be filled out 24 hours before your appointment to ensure that answers given are still valid. Please note this form must be submitted prior to your appointment. Failure to do so will prohibit appointments from entering the Agency and may result in the loss of appointment. If you have any questions or concerns regarding this form please contact the agency at firstname.lastname@example.org or 905-542-8885.Name of Child *Please list the name of the child who has the appointment scheduled.Parent/Guardian Name (First & Last) *Time of Scheduled Appointment *Date of Scheduled Appointment *Have you, your child, or anyone in your household traveled outside of Canada in the last 14 days? Please select.YesNoAre you or your child experiencing any of the following symptoms? *Check all that apply.CoughFeverHeadacheWeaknessDifficulty BreathingLoss of Taste and/or SmellChillsNone of the aboveDid you provide care for or have close contact with a person with COVID-19? Probable or confirmed. *Please select answer.YesNoEmail *Phone * VerificationPlease enter any two digits *Example: 12This box is for spam protection - <strong>please leave it blank</strong>: If you are emailing from a hotmail account, please check your junk mail for response or save the above email to your address book.