COVID-19 Pre-Screening Form

Please fill out the form below 7 days prior to your appointment:

    Have you tested positive for COVID-19?

    Are you awaiting results for a COVID-19 test?

    Do you have a fever over 37.8°C (100.4°F) or chills?

    Do you have a new or worsening cough?

    Do you have a sore throat?

    Do you have a runny nose or nasal congestion that you wouldn't normally have because of seasonal allergies or another pre-existing condition?

    Do you have other cold- or flu-like symptoms?

    Are you having new or worsening shortness of breath or other difficulties breathing?

    Have you experienced a recent loss of taste or smell?

    Are you feeling tired or fatigued without explanation?

    Do you have a new or worsening headache?

    Do you have nausea, vomiting, diarrhea or abdominal pain?

    Even if you do not currently have any of the above symptoms, have you experienced any of these symptoms in the last 14 days?

    Have you returned from travel outside of Canada in the past 14 days?


    Press the button below to submit the completed screening form.