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Riverbend Pharmacy And Medical Clinic
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2-1866 Oxford St W, London, ON N6K 0J8
519.472.3888
info@riverbendpharm.com
Riverbend Screener
Name
(Required)
First
Last
Phone
(Required)
Email
(Required)
Date of Birth
(Required)
Month
Day
Year
1.) Have you received your final (or second) Covid-19 Vaccinations more than 14 days ago?
(Required)
Yes
No
A fully immunized individual is defined as any individual >14 days after receiving their second dose of a two-dose COVID-19 vaccine series or their first dose of a one-dose COVID-19 vaccine series (i.e .Johnson and Johnson).
2) Have you travelled outside of Canada in the past 14 days AND been advised by a doctor, health care provider or public health unit to self-isolate (staying at home)?
(Required)
Yes
No
3) Have you had close contact with a confirmed case of COVID-19 without wearing appropriate PPE in the past 14 days?
(Required)
Yes
No
4.) Do Any of the following apply
A.) You live with someone who is currently isolating because of a positive COVID-19 test
(Required)
Yes
No
B) You live with someone who is currently isolating because of COVID-19 symptoms
(Required)
Yes
No
C) You live with someone who is waiting for COVID-19 test results
(Required)
Yes
No
5.) Do you have any of the following Symptoms
A.) Fever and/ or chills
(Required)
Yes
No
B.) New onset of cough or worsening chronic cough?
(Required)
Yes
No
C.) Shortness of breath?
(Required)
Yes
No
D.) Decrease or loss of sense of taste or smell?
(Required)
Yes
No
6.) Please answer the following questions
A.) I am an adult (18 years or older) or completing on behalf of an adult who has problems with vision or cognition, and I (or the person entering the clinic) has unexplained fatigue/lethargy/malaise/muscle aches.
(Required)
Yes
No
B.) I am completing this form on behalf of a child (under 18 years old), and they have nausea/vomiting, diarrhea
(Required)
Yes
No
Name and Phone Number of the individual that is completing this screening form.
Name
(Required)
First Name
Last Name
First name and last name of individual completing this screening form
Phone
(Required)
Phone Number of the individual completing this screening form.
7.) Have you tested positive for COVID-19 in the past 10 days or have been told you should be isolating?
(Required)
Yes
No
By pressing submit, I attest that, to the best of my knowledge and belief, all information in the above referenced Patient COVID Screening is accurate and complete.
