COVID19 Screening Questions Please answer the following COVID19 Screening Questions.Legal Name* First Last Name you go by (if different than above) First Last Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Do you have an acute respiratory illness?*YesNoHave you travelled outside of Ontario in the past 14 days?*YesNoHave you been in contact with someone who has a confirmed or suspected case of COVID19?*YesNoDo you have a fever, new onset cough or difficulty breathing?*YesNoDo you have 2 or more of the following -- chills, fatigue, a headache, runny nose, sore throat, difficulty swallowing, hoarse voice, stuffy or congested nose, lost sense of taste or smell, digestive issues (nausea/vomiting, diarrhea, stomach pain)? For young children / infants: sluggish or lack of appetite?*YesNoIf 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 519 832 5511 or email us to rebook your appointment.** COVID19 Policies ** Masks are mandatory for anyone over the age of 2 and must be worn at all times, covering the mouth and nose. If you don't have a mask at the time of your appointment, one will be provided for you. If you are unable to wear a mask for any reason, we will need to postpone your visit. Face shields worn without masks cannot be worn in place of a mask. We ask that all patients attend their appointments alone, with the exception of a caregiver bringing someone to their appointment. We ask that children not attend the appointment unless they are the ones being examined. Any extra people brought to the appointment will be asked to wait outside. We ask that upon entering our office, that you immediately wash your hands with soap and water or hand sanitizer. If your appointment needs to be rescheduled due to tardiness or if you are unable to attend, you will need to give us 24 hours notice, otherwise there will be a $75 no-show fee. Because we have had to significantly reduce the number of patients we're able to see in our office, we have had to implement this strict policy. 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.
