Section 1 of 1 in this document
Apex Surgical COVID-19 Form
Surgical Patient Assessment Form - Adult
Full Name
First Name
*
Last Name
*
Email
*
In the last 14 days have you:
Returned from travel outside of Canada?
*
Choose One
Yes
No
Been in close contact with anyone diagnosed with lab confirmed COVID-19?
*
Choose One
Yes
No
Lived or worked in a setting that is part of a COVID-19 outbreak?
*
Choose One
Yes
No
Been advised to self-isolate or quarantine at home by public health?
*
Choose One
Yes
No
Do you have any COVID-19 like symptoms?
*
Choose One
Yes
No
disregard this