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