Mandatory COVID-19 Patient Screening Must be completed before your appointment date. All fields are required First Name (required) Last Name (required) Email (required) Phone Number (required) Have you had close contact with anyone with acute respiratory Illness or travelled outside of Ontario in the past 14 days? (required)—Please choose an option—YesNo Have you tested positive for COVID-19 or had close contact with a confirmed case of COVID-19? (required)—Please choose an option—YesNo Are you experiencing any of the following symptoms? FeverNew onset of coughWorsening chronic coughShortness of breathDifficulty breathingSore throatDifficulty swallowingDecrease or loss of sense of taste or smellChillsHeadachesUnexplained fatigue/malaise/muscle aches (myalgias) Nausea/vomiting, diarrhea, abdominal painPink eye (conjunctivitis)Runny nose/nasal congestion without other known cause If you are 70 years of age or older, are you experiencing any of the following symptoms? DeliriumUnexplained or increased number of fallsAcute functional decline or worsening of chronic conditions Δ
