If you are experiencing one or more of the following symptoms: new or worsening chest pain, sudden onset of facial droop, weakness or numbness on one side of your body, changes to speech, changes to vision, or loss of balance, please proceed to the back and report to the nursing station immediately.

Patient Information

Name

Date of Birth (YYYY-MM-DD)

Age

Reason for Visit

Have you travelled outside of Canada in the last 21 days?

Yes