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Riverbend Pharmacy And Medical Clinic
Annual Physical Exam
Covid 19 Booster Shot
Covid 19 Rapid Testing
Covid 19 Vaccine
Covid-19 Screener Fail
Covid-19 Screener Pass
Ear Nose And Throat
Health and Wellness
Knee and Joints
Lower Back and Legs
Monitoring and Assessments
MTO Physical Exam
Neck and Upper Back
Online Prescription Refill
Online Prescription Transfer
Pregnancy and Maternity
Riverbend Walk In Clinic
Seasonal Flu Shot
Terms & Conditions
Well Child Exams
Well Women Exam
2-1866 Oxford St W, London, ON N6K 0J8
Date of Birth
1.) Have you received your final (or second) Covid-19 Vaccinations more than 14 days ago?
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)?
3) Have you had close contact with a confirmed case of COVID-19 without wearing appropriate PPE in the past 14 days?
4.) Do Any of the following apply
A.) You live with someone who is currently isolating because of a positive COVID-19 test
B) You live with someone who is currently isolating because of COVID-19 symptoms
C) You live with someone who is waiting for COVID-19 test results
5.) Do you have any of the following Symptoms
A.) Fever and/ or chills
B.) New onset of cough or worsening chronic cough?
C.) Shortness of breath?
D.) Decrease or loss of sense of taste or smell?
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.
B.) I am completing this form on behalf of a child (under 18 years old), and they have nausea/vomiting, diarrhea
Name and Phone Number of the individual that is completing this screening form.
First name and last name of individual completing this screening form
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?
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.