COVID-19 Questionnaire - Peace Arch Dental

In the past 14 days have you or any of your family members travelled to outside of Canada?*

Countries Travelled*

In the past 14 days have you or any household member had any contact with a known COVID 19 patient?*

Have you or any household member have a history of exposure to COVID 19 biological material?*

Have you had a history of fever in the past 14 days?*

Have you had any respiratory illness such as cough or difficulty breathing in the past 14 days?*