COVID-19 Screening Questionnaire

You must complete this screening questionnaire before each appointment

Please correct the errors described below.

Patient Information

Appointment Information

You must complete this COVID-19 screening questionnaire before each visit to our office on the day before your visit. Please confirm today's date and the date of your appointment.

Symptom History

Have you experienced any of the following symptoms in the past 14 days?

Contact History

For those over age 70

Please complete this questionnaire again if any of your answers change before your appointment.

Remember to wear a mask when entering the office. At this time, the public office washroom is currently closed.

Your information will be encrypted.