COVID | kristageorgeacu

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Please complete this screening form 24-48 hours in advance of your acupuncture appointment.

First Name

Last Name

Phone Number

Did you travel outside of Canada in the past 14 days?

No

Yes

Have you tested positive for COVID-19 OR had close contact with a confirmed case of COVID-19 without wearing appropriate PPE?

No

Yes

Do you have any of the following symptoms?

Fever

New onset of cough

Worsening chronic cough

Shortness of breath

Difficulty breathing

Sore throat

Difficulty swallowing

Decrease of loss of sense of taste or smell

Chills

Headaches (with no history)

Unexplained fatigue/malaise/muscle aches (myalgias)

Nausea/vomiting, diarrhea, abdominal pain

Pink eye (conjunctivitis)

Runny nose or nasal congestion without other known cause

(If 70 years of age or older) Delirium Unexplained or increased number of falls

(If 70 years of age or older) Acute functional decline

(If 70 years of age or older) Worsening of chronic conditions

None of the Above

Full Name

Today's Date

I declare that the info I’ve provided is accurate & complete

CLINIC HOURS

TUESDAY 3:00 - 8:00pm

WEDNESDAY 12:00 - 5:00pm

SATURDAY 9:00am - 1:00pm

Contact for off hour appointment

ACUPUNCTURE CLINIC

75 Grandview Drive

CONESTOGO, ON N0B 1N0

TEL.519-572-1115

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