COVID 19: Appointment Pre-Screen and Consent

If instructed by the front desk, please fill out our online form as soon as possible.

Please Fill Out These Forms Before Your Upcoming Appointment

Please call reception immediately if you have a positive result to any of the questions. Thank you

Please fill out all fields that apply.

Patient Acknowledgement Form

Patient Acknowledgement

Acknowledgement Options *

Patient Screening

Do you have a fever or have felt hot or feverish anytime in the last two weeks? *
Have you had any of these symptoms in the last 2 weeks: Dry cough? Shortness of breath? Difficulty breathing? Sore throat or painful swallowing? Runny nose? Sneezing? Postnasal drip? Loss of appetite? Chills? Muscle ache? Headache? Fatigue? *
Have you experienced a recent loss of smell or taste? *
Have you been in contact with anyone who is sick, or any persons self-isolating or who have COVID-19? *
Have you returned from travel outside of Canada in the last 14 days? *
Have you returned from travel within Canada from a location known to be affected with COVID-19 (eg. visited a restaurant with a confirmed COVID -19 case) *
Is your workplace considered high risk? *
Are you over the age of 70? *
Do you have any of the following? Serious heart disease, serious lung disease, chronic kidney disease (or on dialysis), diabetes, severe obesity, or liver disease? Are you immunocompromised or pregnant? *
Please read the statement below and check the box
COVID-19 Steps We Are TakingPlease read before your appointment