COVID-19 Screening

Covid-19 Screening Form

Let's work together to stay life! Before every visit please fill out our COVID-19 Screening Form

Please fill out this mandatory COVID-19 screening form before attending our programs. Your response will be recorded and assessed by our team, so please ensure your information is accurate.

You will be required to fill out a digital signature at the bottom of this form which affirms that your answers are true and complete to the best of your knowledge.











  • Fever
  • New onset of cough or worsening chronic cough
  • Shortness of breath or difficulty breathing
  • Sore throat or difficulty swallowing
  • Headaches
  • Chills
  • Decrease or loss of taste/smell
  • Unexplained fatigue, malaise, muscle aches (myalgias)
  • Runny nose/nasal congestion without other known cause
  • Nausea/vomiting, diarrhea, abdominal pain
  • Pink eye (conjunctivitis)







Can You help us?

Can You Help Us?

132 Church Street
2nd Floor
Bowmanville, ON L1C 1T5

Landline: 905-419-7900
Admin: 289-278-3489
info@autismhomebase.com

Autism Home Base is a proud member of

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132 Church Street
2nd Floor
Bowmanville, ON  L1C 1T5

Landline: (905) 419-7900
Admin: (289) 278-3489
info@autismhomebase.com

Autism Home Base is a proud member of

A proud member of

132 Church Street

2nd Floor

Bowmanville, ON

L1C 1T5

(289) 278-3489

info@autismhomebase.com

A Registered Canadian Charity

#81352 5797RR0001

Terms of Use   |   Privacy Policy

A proud member of

132 Church Street

2nd Floor

Bowmanville, ON

L1C 1T5

(289) 278-3489

info@autismhomebase.com

A Registered Canadian Charity

#81352 5797RR0001

Terms of Use   |   Privacy Policy

A Registered Canadian Charity #81352 5797RR0001

© 2012-2020 Autism Home Base Durham Inc. • All rights reserved.