FORM 2 - COMPLETE THIS FORM TO CONFIRM THE APPOINTMENT

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In response to COVID-19, additional steps have been taken to further enhance your safety and the safety of our staff.

Email *

Full Name: *

Accompanying persons are not permitted to enter, except for caregivers.

Delivery Personnel are to contact the facility staff prior to entering.

Please review the following questions to confirm your fitness to enter the facility.

Do you currently have any of the following symptoms?

Severe Cough? *

Yes

Muscle pains? *

Yes

Significant Nasal Congestion? *

Yes

Fever > 38°C? *

Yes

Shortness of breath? *

Yes

Headache? *

Yes

Runny nose? *

Yes

Reduced or lost sense of smell? *

Yes

Have you failed to use physical distancing in the last two weeks? *

Yes

Have you come into contact with anyone suspected of having Covid-19 in the last 2 weeks? *

Yes

Have you come into contact with anyone diagnosed of having Covid-19 in the past 2 weeks? *

Yes

If you answered "YES" to any of the above questions,

Call our number below and you will be given the appropriate direction.

Only enter the clinic if you answered "No" to all the questions above.

Call us if you have any questions: 905 770 2006

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