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UHMC pre-appointment screening 2022
Please complete this form within 24 hours of your appointment. Update us ASAP if any of your replies change after you submit the form.
* Required
Email
*
Your email
Please enter the full name of booked patient:
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Your answer
Please acknowledge patients must enter alone, except in certain circumstances (to be authorized by physician):
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yes, I will attend alone
no, patient is UNDER 16: please fill a second survey for the one parent/guardian attending the appointment
The patient is disabled/cognitively impaired and requires an attendant: please fill a second survey for the attendant
The patient requires translation: please fill second survey for translator
Other:
Each person entering the clinic must submit a SEPARATE survey. Please advise to whom this survey applies:
*
the booked patient named above
another person requesting or required to attend the appointment (must enter name in next question AND submit a separate survey)
If this survey entry applies to a family member/attendant, please enter name and relationship to the patient:
Your answer
Have you experienced any FEVER in the past few days?
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yes
no
Have you experienced any COUGH in the past few days?
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yes
no
Have you experienced any other respiratory symptoms in the past few days? (includes sore throat, runny nose, ear/sinus pain, shortness of breath, etc.)
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yes
no
if you answered YES to any question, please list your symptom and when they began:
Your answer
Please list any travel outside of Ontario in the last 30 days (include date of return and destination of travel), or enter "NONE" if you have not travelled:
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Your answer
Have you been in contact with anyone in the past 2 weeks who has recently travelled, or recently been ill? Please explain or enter "NO":
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Your answer
Have you been in contact in the last 30 days with anyone who has a known or suspected case of Covid-19?
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yes
no
Please bring a mask, and stay in your vehicle upon arrival for your appointment. Text us at: 647-267-5709 to alert us of your arrival.
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I will text upon arrival
I do not have a cell phone/unable to text
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