Dr. Francis La Couvée · Dr. Simon Gooch · 250-752-7524

 

Patient Screening Form

Please take a moment to answer these few questions before your visit to ensure we're keeping all patients as safe as possible. 

Personal Information

(if done by another family member)

Screening Questions

Please choose YES or NO for each of the following questions

Do you have any symptoms of:  Dry cough?  Shortness of breath? Difficulty breathing? Sore throat, fever, or any flu like Symptoms in the last 2 weeks?

Have you been in contact with any confirmed COVID-19 positive patients, or persons self-isolating because of a determined risk for COVID-19?

Have you been in contact with any confirmed COVID-19 positive patients, or persons self-isolating because of a determined risk for COVID-19?

Patient Vulnerability

Please choose YES or NO for each of the following questions

Have you had any changes to your health, or have you been hospitalized in the last year?

To the best of your knowledge are you considered in good health?

Any “yes” response for questions 1-3 please call our office to discuss how to further proceed.

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