COVID-19 Questionnaire

Name: Neighbourhood Pet Clinic
Address: 746 Waterloo Street, London, ON, N6A 3W3, Canada
Telephone: 519-649-0080
Price range: $

Anyone who enters Blue Cross Animal Hospital must sanitize their hands upon entry, pass a COVID-19 questionnaire, and wear a mask properly for the full duration of their time inside.

If you wish to enter the building, please complete the following form:

Name *

First

Last

Furry Family Member's Name *

Phone *

Email *

Should you currently be self-isolating? *

Are you currently experiencing: Breathing difficulties, chest pain, confusion, loss of consciousness Fever/chills, cough, shortness of breath, decrease of taste or smell, muscle aches/joint pain, extreme tiredness? *

In the last 5 days, have you been identified as a “close contact” of someone who currently has COVID-19? *

In the last 10 days, has someone you live with: been sick with symptoms associated with COVID-19? and/or tested positive for COVID-19 (on a rapid antigen test or PCR test)? *

In the last 14 days, have you travelled outside of Canada? (If you are exempt from federal quarantine requirements due to being fully vaccinated or an essential cross-border worker, select NO) *

Name

Appointment Request

Are you a new or existing client?

New Client

Existing Client