Patient Pre-Screening Form
Please fill in this form at least 1 week - 48 hours prior to your appointment.
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REMINDER: All patients must wait in their vehicle and call the office upon arrival. All patients are required to wear a mask and sanitize their hands upon entering the office.
Patient Name: *
Patient Age: *
Have you had close contact with anyone with acute respiratory illness or travelled outside of Canada in the past 14 days? *
Do you have a confirmed case of Covid-19 or had close contact with a confirmed case of Covid-19? *
Do you have any of the following symptoms: *
Required
If you are 70 years of age or older, are you experiencing any of the following symptoms: delirium, unexplained or increased number of falls, acute functional decline, or worsening of chronic conditions? *
If YES which of the following are you experiencing:
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