Good day! Are you an EXISTING or NEW patient?

Existing

New

Did you travel outside of Canada over the past 14 days?

Yes

No

Have you tested positive for COVID-19 within the past 14 days?

Yes

No

If you have tested positive for COVID-19, when was the result reported to you? Please enter the date below.

Have you had close contact with a confirmed case of COVID-19 without wearing appropriate PPE over the past 14 days?

Yes

No

Have you had any of the following symptoms over the past 14 days?

Fever

Yes

No

New onset of cough

Yes

No

Worsening chronic cough

Yes

No

Shortness of breath

Yes

No

Difficulty breathing

Yes

No

Sore throat

Yes

No

Difficulty swallowing

Yes

No

Chills

Yes

No

Decrease of loss of sense of taste or smell

Yes

No

Headaches

Yes

No

Unexplained fatigue/malaise/muscle aches (myalgias)

Yes

No

Nausea/vomiting, diarrhea, abdominal pain

Yes

No

Pink eye (conjunctivitis)

Yes

No

Runny nose or nasal congestion without other known cause

Yes

No

How many doses of Covid vaccine did you take? (Please ignore if you do not wish to answer!)

1 dose

2 doses

3 doses

4 doses

Never

I consent to the practitioner(s) storing my submitted information. The practitioner(s) can respond to my input by either email, phone or text messages. Please note that this Covid Prescreening process is required by Health Ontario.

Mobile Number

Email

Appointment Date

Please On-screen Signature below:

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Covid Pre-Screening Form