COVID-19 Screening Form

Please answer the following questions - all fields are required

First and Last Name *

Email *

Have you experienced a recent loss of smell or taste? *
SelectYesNo

Are you currently experiencing one or more of the following symptoms that are new or worsening: fever (37.8 C or higher), cough or barking cough, unusual tiredness (Symptoms should not be chronic or related to other known conditions) *
SelectYesNo

Do you have any of the following symptoms: shortness of breath, difficulty breathing, sore throat, runny nose, headache, fatigue, nausea/vomiting, diarrhea, abdominal pain, or pink eye? *
SelectYesNo

Have you been in contact with any confirmed COVID-19 positive patients, or persons self-isolating because of a determined risk for COVID-19 since your completion date of isolation? *
SelectYesNo

Is anyone you live with currently experiencing any new COVID-19 symptoms and/or waiting for test results after experiencing symptoms? *
SelectYesNo

Have you returned from travel outside Canada in the last 14 days and been advised to quarantine as per federal quarantine requirements? *
SelectYesNo

Are you awaiting a lab test to confirm COVID-19? *
SelectYesNo

Has a doctor, health care provider, or public health unit told you that you should currently be isolating? This can be because of an outbreak or contact tracing. *
SelectYesNo

In the last 10 days, have you received a COVID Alert exposure notification on your cell phone? *
SelectYesNo

In the last 10 days, have you tested positive on a rapid antigen test or a home-based self-testing kit? *
SelectYesNo

Your temperature will be taken by one of our team members once you enter our office. If your temperature is 37.8° C (100° F), your appointment will be rescheduled. If you have recorded your temperature at home and it is 37.8° C (100° F), we ask that you call the office to reschedule your appointment. Thank you for your cooperation.