Patient Screening Form
COVID-19 Screening Questions
Do you have a fever or have you felt hot or feverish recently (within 14-21 days)?
Are you having shortness of breath of other difficulties breathing?
Do you have a cough?
Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigure?
Have you experienced recent loss of taste or smell?
Are you in contact with any confirmed COVID-19 positive patients?
Have you traveled in the past 14 days to any regions affected by COVID-19?
Date(s) for any pre-appointment YES responses:
Should be Empty: