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