EmailMe Form - COVID-19 Screening Survey [OLD]

Name of Patient being Treated *

First Last

Did you receive your final (or second) vaccination dose more than 14 days ago? *

Yes

No

Do you have any of the following symptoms:
• Fever and/or chills
• New onset of cough or worsening chronic cough
• Shortness of breath
• Decrease or loss of sense of taste or smell
• If adult >18 years of age: unexplained fatigue/lethargy/malaise/muscle aches
• If child <18 years of age: nausea/vomiting, diarrhea *

Yes

No

Have you tested positive for COVID-19 in the past 10 days or have you been told you should be isolating? *

Yes

No

Have you travelled outside of Canada within the last 14 days? *

Yes

No

Have you had close contact with a confirmed case of COVID-19 without wearing appropriate PPE? *

Yes

No

I, verify that the answers I provided on this form to be truthful and honest. It is my responsibility to notify the office if any of the answer changes before my appointment. *

Yes

No

In an effort to keep everyone safe during this time, we have made the following changes:

1. Please wear your own mask when you enter the office. If you arrive without a mask, one will be provided to you.

2. When you arrive, please call our office and wait in your car. We will let you know when you can come in.

3. Only individuals being treated can enter the clinic. Accompanying persons are not permitted to enter, except for caregivers.

4. You will be asked to use hand sanitizer when you enter and exit the office.

5. We will ask some screening questions again, related to COVID-19 as well as take your temperature.

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