Request For An Appointment

Please fill out the appointment request form below, we’ll give you a call to set up an appointment immediately.

Health Pre-screening Form for COVID19

Name

First Name

Last Name

Email

Are you experiencing any of the followings? Please check the box if this applies to you.

if you have one of the following symptoms, we won't be abel to offer you a service and will ask you to reschedule your appointment.

Severe difficulty breathing

Severe chest pain

Feeling confused

Losing consciousness

Mild to moderate shortness of breath

None of the above

Are you experiencing cold, flu or COVID-19-like symptoms, even mild ones?

Symptoms include: fever, chills, cough, shortness of breath, sore throat and painful swallowing, stuffy or runny nose, loss of sense of smell, headache, muscle aches, fatigue or loss of appetite

Have you travelled to any countries outside Canada (including the United States) within the last 14 days?

Did you have provided care or have close contact with a person with confirmed COVID-19?

Note: This means you would have been contacted by your health authority’s public health team

Type your name below as your digital signature

Today's date

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Request For An Appointment

Health Pre-screening Form for COVID19

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