COVID-19 Screening

Before visiting Secura, we ask that you complete this short screening form. In accordance with Ontario guidelines, we must actively screen all persons, whether or not they have been vaccinated.

Once the form is submitted, a receipt of your responses will automatically be forwarded to our staff. Thank you for taking the time to keep everyone safe!

1) 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.


Fever and/or Chills
Cough and/or barking cough
Shortness of breath
Decrease or loss of taste and/or smell
Sore throat or trouble swallowing
Runny or stuffy nose
Abdominal pain that is persistent or ongoing (not related to known causes or conditions)
Headache that is unusual or long lasting
Conjunctivitis (pink eye)
A decreased or lack of appetite
Tiredness, muscle aches or joint pain

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

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


This can be because of an outbreak or contact tracing

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


If public health has advised you that you do not need to self-isolate, select “No.”

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


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."

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


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

7) In the last 10 days, has 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?


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


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 selected "No" to all of the questions above, we look forward to seeing you at Secura! Thank you for your time.