NATS Brampton
COVID-19 Waiver and Screening Form

Please complete this active screening process for each Medix College facility you visit for contact tracing purposes.


Please review the information below:

(1) Are you currently experiencing any of these symptoms?

  1. Fever or chills
  2. Cough, croup (squeaky or whistling nose when breathing), severe difficulty breathing or shortness of breath
  3. Sore throat, hoarse voice or difficulty swallowing
  4. Stuffy, congested or runny nose
  5. Severe chest pains
  6. Loss of consciousness
  7. Feeling confused or unsure of where you are
  8. Not feeling well
  9. Falling down often
  10. Fatigue* that is unusual, lack of energy or sluggishness
  11. Muscle aches or joint pain* that is unusual or long lasting
  12. Headache* that is unusual or long lasting
  13. Pink eye
  14. Decrease in or loss of smell or taste
  15. Lack of appetite
  16. Digestive issues (nausea/vomiting, diarrhea or stomach pain)

(2) In the last 10 days, have you tested positive on a COVID-19 rapid antigen test, a self-testing kit or have been tested and are awaiting results? 

(3) Have you been directed by Public Health, a physician or other healthcare professional to self-isolate for a period of time including today? 

(3) In the last 14 days, have you had close contact* with someone who has or is suspected of having COVID-19 (including exhibiting any of the listed symptoms** and/or awaiting test results)? 

By clicking an option below,  I hereby certify the above information is accurate to the best of my knowledge.

Did you answer YES to ANY of the above questions?

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