COVID19 Screening Questions "*" indicates required fields Please answer the following COVID19 Screening Questions.Legal Name* First Last Name you go by (if different than above) First Last Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2024202320222021202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925192419231922192119201. Are you currently experiencing cold or flu symptoms that are new or worsening?**YesNoSymptoms should not be chronic or related to other known causes or conditions. Fever and/or chills (37.8C/100F or higher), cough or barking cough, shortness of breath, sore throat or difficulty swallowing, decrease or loss of smell or taste, pink eye, runny or stuffy/congested nose2. Have you been asked to quarantine?**YesNo3. In the last 6 days, have you tested positive for COVID?**YesNo4. Has anyone you live with tested positive for COVID in the last 6 days?**YesNo**If you answered YES to ANY of the above questions we will have to reschedule your appointment, for the safety of our staff and other patients. Please call or text us at 519 832 5511 or email us to reschedule your appointment.** COVID19 Policies ** If any of the answers to these screening questions change before your appointment, this screening result is no longer valid and you may need to screen again, wherever necessary. Please give us 24 hours notice if you need to reschedule. Any record created as part of screening may only be disclosed as required by law. Thank you for your understanding!Agreement of COVID19 Policies* I have answered NO to the above screening questions AND have read and agree to the above COVID19 Policies.
