मार्खम ईयर, एन ओएस और गला क्लिनिक

टी: (289) 800-7128

एफ: (289) 800-9615

कोविड -19 प्री-स्क्रीनिंग
समर्थन व्यक्ति के लिए

Please specify your role as a Support Person:

Parent/Guardian of a patient under 18 years old

Accompany a patient with mobility support requirement

Support a patient with developmental disablity/cognitive impairment

Provide translation for a patient who does not speak Cantonese/English

पूरा नाम

फ़ोन

Do you have one or more of the following symptom(s) without known cause?

Yes

Have you been tested positive for COVID-19 or had close contact with a confimed or suspected case of COVID-19?

Yes

Have you travelled outside of Canada in last 14 days?

Yes

Have you vaccinated against COVID-19?

Yes

If Yes, how many doses?

मैं घोषणा करता/करती हूं कि मेरे द्वारा प्रदान की गई जानकारी मेरी जानकारी के अनुसार सटीक है।

आपने सफलतापूर्वक फॉर्म जमा कर दिया है!