COVID-19 Screening Checklist

As you know, COVID-19 continues to evolve quickly. Given this, we are conducting active screening for potential risks of COVID-19 for everyone entering our clinic to ensure the safety and well being of our patients and staff.

Please complete the form below – all fields are required.

1. Do you have a fever?
2. Do you have a new / worsening cough?
3. Do you have shortness of breath or difficulty breathing?
4. Do you have a sore throat?
5. Do you have a runny nose?
6. Do you have pink eye?
7. Any new unexplained symptoms of fatigue and generalized muscle aches?
8. New vomiting / diarrhea / abdominal pain?
9. New loss of smell / taste?
10. Have you travelled outside of Canada in the past 14 days?
11. Have you had close, unprotected contact with a confirmed case or probable case of COVID-19?
Your First Name

Your Last Name

Your Date of Birth

Your Appointment Date

Your Appointment Time