Patient Name *

Patient Age *

Parents or Legal Guardians Name if Patient is a Minor:

1. Have you (or the patient if a minor) tested positive for COVID-19 in the past month or are you waiting for results from COVID19 testing? *

Yes

2. Have you (or the patient, if a minor) been in contact with any person who has been diagnosed with COVID-19 in the last 5 Days? *

Yes

3. Have you (or the patient if a minor) been advised by your physician or provincial health authority to individually quarantine due to a possible exposure to COVID-19? *

Yes

2. Do you have or have you recently had (within the past 5 days) any of the following symptoms (or the patient if a minor):

Fever above (37 degrees Celsius) or feeling hot, chills/feverish *

Yes

Repetitive or chronic coughing *

Yes

Shortness of breath or difficulties breathing *

Yes

Sore throat or painful swallowing *

Yes

A loss of taste or smell *

Yes

General or specific muscle pain not normally experienced *

Yes

General flu like symptoms including a runny nose, upset stomach, diarrhea or headache *

Yes

3. Have you (or the patient if a minor) been in contact in the past 5 days with anyone with confirmed COVID-19 or with any of the above symptoms of possible COVID-19? *

Yes

4. Have you (or the patient if a minor) travelled in the last 5 days to any areas significantly impacted by COVID-19 *

Yes

5. In the past 5 days, have you (or the patient if a minor) been to any large gatherings where social distancing was not observed? *

Yes

6. Do you (or the patient if a minor) have heart, lung or kidney disease, diabetes, or any auto-immune disorders? *

Yes

By clicking here and printing my name below, I confirm that I know there are categories of people who are considered to be at high risk. I understand the high-risk category factors are being 65 years of age or older, heart disease, lung disease, kidney disease, diabetes or any auto-immune disorder. If I (or the patient I am completing this form for) are in one of these categories I have chosen to proceed with my (or the patients) appointment knowing the risk to my (or the patients) health if I (or the patient) develop COVID-19. I confirm that if there are any changes to the above answers from the time I complete this form to the time of my (or the patient in the case of a minor) appointment, I will let the office know.

Please Type the First & Last Name of Person Completing This Form *

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