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COVID-19 Pre-Screening

Before coming into our offices, we ask that you complete the following COVID-19 pre-screening form.

All information gathered is used exclusively for the purposes of ensuring the health and safety of the residents, guests, and employees of Spark Law.

Name *

First

Last

Please enter your telephone number: *

Please provide your email address *

Email

Confirm Email

Who are you visiting? *

What is the date and time of your appointment? *

Date

Time

Vaccination Status

Have you received two full doses of a Health Canada approved COVID-19 vaccine, and if so, was your last dose more than 14 days ago? *

Yes
No

Do you have a medical or religious reason for not having been vaccinated against COVID-19? *

Yes
No

What is the medical or religious reason for not having been vaccinated? *

Please provide some details of the reason so that we can ensure that your needs are properly accommodated.

Are you currently experiencing one or more of the symptoms below that are new or worsening? Symptoms should not be chronic or related to other known causes or conditions.

Even if you are fully vaccinated, you must answer the following questions.

Fever and/or chills - Temperature of 37.8C/100F or higher

Yes
No

Cough or barking cough (croup) - Not related to asthma, post-infectious reactive airways, COPD, or other known causes or conditions you already have

Yes
No

Shortness of breath - Not related to seasonal allergies, neurological disorders, or other known causes or conditions you already have

Yes
No

Fatigue. lethargy, malaise and/or myalgias - Unusual tiredness, lack of energy (not related to depression, insomnia, thyroid dysfunction, or other known causes or conditions you already have)

Yes
No

Decrease or loss of smell or taste - Not related to seasonal allergies, neurological disorders, or other known causes or conditions you already have

Yes
No

Travel and Contact

In the last 14 days, have you travelled outside of Canada AND been advised to quarantine (as per the federal quarantine requirements)? *

Yes
No

Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)? *

Yes
No

This can be because of an outbreak or contact tracing.

In the last 10 days, have you been identified as a “close contact” of someone who currently has COVID-19? *

Yes
No

If public health has advised you that you do not need to self-isolate (e.g., you are fully immunized* or have tested positive for COVID-19 in the last 90 days and since been cleared), select “No.”

In the last 10 days, have you received a COVID Alert exposure notification on your cell phone? *

Yes
No

If you have already gone for a test and got a negative result, select "No." If you are fully immunized or have tested positive for COVID-19 in the last 90 days and since been cleared, select "No."

In the last 10 days, have you tested positive on a rapid antigen test or a home-based self-testing kit? *

Yes
No

If you have since tested negative on a lab-based PCR test, select “No.”

In the last 14 days, has someone in your household (someone you live with) travelled outside of Canada AND been advised to quarantine (as per the federal quarantine requirements) in the last 14 days? *

Yes
No

If you are fully immunized or have tested positive for COVID-19 in the last 90 days andsince been cleared, select “No.”

In the last 10 days, has someone in your household (someone you live with) been identified as a ”close contact” of someone who currently has COVID-19 AND advised by a doctor, healthcare provider or public health unit to self-isolate in the last 10 days? *

Yes
No

If you are fully immunized or have tested positive for COVID-19 in the last 90 days andsince been cleared, select “No.”

Is anyone you live with currently experiencing any new COVID-19 symptoms and/or waiting for test results after experiencing symptoms? *

Yes
No

If the individual experiencing symptoms received a COVID-19 vaccination in the last 48 hours and is experiencing mild fatigue, muscle aches, and/or joint pain that only began after vaccination, select “No.” If you are fully vaccinated or have tested positive for COVID-19 in the last 90 days and since been cleared, select “No.”

416.639.2150
647.490.4888

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100 Lombard Street, Suite 205 Toronto, ON M5C 1M3
6-2557 Dougall Ave., Suite 429, Windsor, ON N8X 1T5