ATHX

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First Name

Last Name

Do you have any of the following symptoms:fever/feverish, new or existing cough and difficulty breathing?

Yes

No

Have you traveled internationally within the last 14 days (outside Canada)?

Yes

No

Have you had close contact with a confirmed or probable COVID-19 Case?

Yes

No

Have you had close contact with a person with acute respiratory illness who has been outside Canada in the last 14 days?

Yes

No

If you answered yes to the above we unfortunately are unable to treat you today please contact 811

Tel: 780-430-9224

18019 111 AVE NW

EDMONTON, AB, T5S 2P2

CONTACT:

780-430-9224 EXT 1