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.
Email *
Please enter the full name of booked patient: *
Please acknowledge patients must enter alone, except in certain circumstances (to be authorized by physician): *
Each person entering the clinic must submit a SEPARATE survey. Please advise to whom this survey applies: *
If this survey entry applies to a family member/attendant, please enter name and relationship to the patient:
Have you experienced any FEVER in the past few days? *
Have you experienced any COUGH in the past few days? *
Have you experienced any other respiratory symptoms in the past few days? (includes sore throat,  runny nose, ear/sinus pain, shortness of breath, etc.) *
if you answered YES to any question, please list your symptom and when they began:
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: *
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": *
Have you been in contact in the last 30 days with anyone who has a known or suspected case of Covid-19? *
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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