Patient Screening Form

This form must be completed 24 to 48 hours prior to your appointment.

First and Last Name *

Phone *

Email *

1) Did you receive your final (or second) vaccination dose more than 14 days ago? *

Yes

No (or do not wish to disclose)

Please answer Questions 2 and 3 below only if you responded No to Question 1.

2) Have you traveled outside of Canada in the last 14 days?

Yes

3) Have you had close contact with a confirmed case of COVID-19 without wearing appropriate PPE?

Yes

4) Do you (or anyone in your household) have any of the following symptoms - Fever and/or chills - New onset of cough or worsening chronic cough - Shortness of breath - Decrease or loss of sense of taste or smell - If adult: 18 years or older: unexplained fatigue/lethargy/malaise/muscle aches (myalgias) - If child: under 18 years of age: nausea/vomiting, diarrhea *

Yes

5) Have you (or anyone in your household) tested positive for COVID-19 in the past 10 days or been told to isolate? *

Yes

Please remember to wear a mask to your appointment.

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COVID-19: Information about appointments & visitsCLICK HERE