Pre appointment Covid 19 Screening Please complete the following prior to your visit today. Name * First Name Last Name 1. Have you had your second dose of a covid 19 vaccine more than 14 days ago? * Yes No 2. If not, have you travelled outside Canada within the last 14 days? Yes No 3. Do you have any of the following symptoms? * Fever or Chills New onset of cough or worsening chronic cough Shortness of breath, Difficulty breathing Unexplained fatigue/malaise/muscle aches (myalgias) Nausea/vomiting, diarrhea, abdominal pain Decrease or loss of sense of taste or smell Yes No 4. Have you tested positive for COVID-19 in the past 10 days or have you been told you should be isolating? * Yes No If response to questions 2 & 3 is No, please come to your appointment. If response to either questions 2 & 3 is YES, , we will be unable to see you and your appointment will be rescheduled. It is recommended you call Telehealth Ontario and/or your medical doctor and discuss these possible symptoms further. Please ensure you are wearing a mask (cloth or disposable) when entering the clinic. Please use the Hand Sanitizer upon arrival. Thank you!
