top of page
COVID-19 Screening Form

Your Name

Do you have fever or have you felt hot or feverish recently (14-21 days)?

arrow&v

Are you having shortness of breath or other difficulties breathing?

arrow&v

Do you have a cough?

arrow&v

Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?

arrow&v

Have you experienced recent loss of taste or smell?

arrow&v

Are you in contact with any confirmed COVID-19 positive patients?

arrow&v

Do you have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?

arrow&v

Have you traveled in the past 14 days to any regions affected by COVID-19?

arrow&v

Thank you! Your answer is recorded.

Request an Appointment

Thanks for submitting!

bottom of page