RENSEIGNEMENTS PERSONNELS / PERSONAL INFORMATION

    Prénom / First Name

    Nom de famille / Last Name

    Courriel / Email

    Numéro de téléphone / Phone Number

    QUESTIONNAIRE COVID-19

    La sécurité de nos patients et de nos employés est notre priorité absolue.
    Nous vous prions de collaborer à nos efforts en répondant à ce court questionnaire.

    The safety of our patients and employees is our top priority.
    We ask for your collaboration by filling out the following questionnaire.

    Avez-vous reçu un diagnostic de la COVID-19? /
    Have you been diagnosed with COVID-19?

    Avez-vous été en contact avec quelqu’un ayant contracté la COVID-19? /
    Have you been in contact with someone who’s been diagnosed with COVID-19?

    Avez-vous fait de la fièvre (38° ou 100,4° F) au cours des deux dernières semaines? /
    Have you had fever (38° or 100.4°F) in the past two weeks?

    Avez-vous ressenti des symptômes inhabituels au cours des 14 derniers jours, tels que:
    Have you experienced unusual symptoms in the last 14 days?

    Toux/Cough
    Difficultés respiratoires / Difficulty breathing
    Perte du goût ou de l’odorat / Loss of taste or smell
    Symptômes d’une gastro-entérite/ Gastroenteritis symptoms
    Autres symptômes de la grippe / Other flu-like symptoms

    Avez-vous voyagé à l’extérieur du pays au cours des deux dernières semaines? /
    Have you travelled outside Canada in the last 14 days?

    Êtes-vous un travailleur de la santé ou de première ligne? /
    Are you a healthcare worker or presently working in a high-risk environment?

    Cohabitez-vous avec un travailleur de la santé ou de première ligne? /
    Are you a household member of a healthcare worker?

    Almost done. You will be redirected to the signature page.

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    MESSAGE FROM CLINIQUE-K REGARDING COVID-19

    Dr. Karl Schwarz and his staff would like to thank you for your continued support of the clinic and your patience while we take necessary precautions. We value the health and safety of our patients and staff above all else. Our safety measures include wearing masks and gloves, taking patient's temperature before entering the clinic, increased cleaning practices, and limiting the number of patients in the clinic at any one time.

    To better serve you during this time we have also upgraded our virtual consultation platform. You can learn more about it here.

    We look forward to seeing you again soon! Please reach out with any questions or concerns via email or phone at 514–508–3555.