Apex Surgical COVID-19 Form

Surgical Patient Assessment Form - Adult

In the last 14 days have you:

Returned from travel outside of Canada?

Been in close contact with anyone diagnosed with lab confirmed COVID-19?

Lived or worked in a setting that is part of a COVID-19 outbreak?

Been advised to self-isolate or quarantine at home by public health?

Do you have any COVID-19 like symptoms?