COVID-19 Patient Pre-Screening Questionnaire

    The following form must be filled out only 24 hours before your appointment and is mandatory.

    It is now mandatory for everyone entering the office to bring their own mask.

    Please answer all the questions below :

    1. Patient's First Name :

    2. Patient's Last name:

    3. Patient's Date of birth: (mm/dd/yyyy)

    4. Does the patient have fever or have they felt hot or feverish recently ( in the last 14 days)? YesNo

    5. Does the patient have shortness of breath or other difficulties breathing? YesNo

    6. Does the patient currently have a cough? YesNo

    7. Does the patient have any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue? YesNo

    8. Has the patient experienced recent loss of taste or smell? YesNo

    9. Has the patient been in contact with any confirmed COVID-19 positive patients? YesNo

    10. Patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment.

    11. Has the patient travelled outside of the province in the past 14 days? YesNo

      * Required