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Better Mobility, Better Life | Toll free: 1-877-863-9069
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1. Have you travelled outside of Canada in the past 14 days?
2. Have you tested positive for COVID-19 or had close contact with a confirmed case of COVID-19 without wearing appropriate PPE?
3. Do you have any of the following symptoms?
Decrease/loss of sense of taste or smell
Worsening chronic cough
Runny nose/nasal congestion with no known cause
Unexplained fatigue/malaise/muscle aches
Nausea/vomiting, diarrhea, abdominal pain
New onset of cough
Shortness of breath
4. If you are 70 years of age or older, do you have any of the following symptoms?
Unexplained or increased number of falls
Acute functional decline
Worsening of chronic conditions
• If you have answered NO to all questions and do not exhibit any of the listed symptoms, then you may proceed with your appointment.
• If you have answered YES to any questions or any symptom then you may be asked to reschedule your appointment and further questioning may be required.
By submitting this form, I certify all information is true and correct to the best of my knowledge.
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