COVID Screening Form

Use this form if your appointment is TODAY. You will likely be outside the office waiting to enter, but you can also complete this just before you leave. This is not to be used when confirming a future appointment (i.e. patient pre-screening). In that case, use this form.

If you would prefer to complete this screening another way, or are having technical difficulties, please phone our office during regular business hours (found on this page).

- Step 1 of 5

Please read each question carefully. Multiple people may be screened using this 1 form.

Is this screening for an appointment today? *

Yes, I am outside the office
Yes, I will be there shortly
No

STOP HERE!

Only use this form when: the appointment is today and are outside, or will be here shortly. If you are confirming a future appointment and need to complete a patient pre-screening, stop and use this form.

Read this!

When you arrive, you will need to text us at our main office phone number, 905-257-7111. Once your screening is done here, we will give you this number again, or you can find it on our home page any time. You may click Next to continue.

Who is completing this screening? *

I am the patient
I am responding on behalf of the patient

e.g. the patient is my child

Important:
If you will be accompanying the patient into the office at their appointment, you will be allowed to complete your own screening at the end.

Screening Questions

For the patient, whom you are responding on behalf of.

Patient's name *

First

Last

Mobile phone (for notification) *

IMPORTANT: When it's time to come in, we'll text / phone you at this number.

Your name *

First

Last

i.e. the person responding on the patient's behalf

Your relationship to the patient *

Q&A for "I am the patient"

(this divider is hidden)

Do you have a confirmed case of COVID-19? *

Have you been in close contact with a confirmed case of COVID-19 without wearing appropriate PPE? *

Have you been in close contact with anyone with acute respiratory illness in the past 14 days? *

Have you travelled outside of Canada in the past 14 days? *

Do you have any of the following symptoms: *

Fever
New onset of cough
Worsening chronic cough
Shortness of breath
Difficulty breathing
Sore throat
Difficulty swallowing
Decrease or loss of sense of taste/smell
Chills
Headaches
Unexplained fatigue/malaise/muscle aches (myalgias)
Nausea/vomiting, diarrhea, abdominal pain
Pink eye (conjunctivitis)
Runny nose/nasal congestion without other known cause

Do you have any of the symptoms listed: *

Q&A for "I am responding on behalf..."

(this divider is hidden)

Does the patient have a confirmed case of COVID-19? *

Has the patient been in close contact with a confirmed case of COVID-19 without wearing appropriate PPE? *

Has the patient been in close contact with anyone with acute respiratory illness in the past 14 days? *

Has the patient travelled outside of Canada in the past 14 days? *

Do you have any of the following symptoms: *

Fever
New onset of cough
Worsening chronic cough
Shortness of breath
Difficulty breathing
Sore throat
Difficulty swallowing
Decrease or loss of sense of taste/smell
Chills
Headaches
Unexplained fatigue/malaise/muscle aches (myalgias)
Nausea/vomiting, diarrhea, abdominal pain
Pink eye (conjunctivitis)
Runny nose/nasal congestion without other known cause

Does the patient have any of the symptoms listed: *

Additional information *

Please describe why 1 or more questions was answered "Yes"

Additional people

Will a second person be entering the office? *

Yes, someone is accompanying me
No

Will a second person be entering the office? *

Yes, I will be accompanying the patient
Yes, someone else will be accompanying the patient
No

Screening for you

Do you have a confirmed case of COVID-19? *

Have you been in close contact with a confirmed case of COVID-19 without wearing appropriate PPE? *

Have you been in close contact with anyone with acute respiratory illness in the past 14 days? *

Have you travelled outside of Canada in the past 14 days? *

Do you have any of the following symptoms: *

Fever
New onset of cough
Worsening chronic cough
Shortness of breath
Difficulty breathing
Sore throat
Difficulty swallowing
Decrease or loss of sense of taste/smell
Chills
Headaches
Unexplained fatigue/malaise/muscle aches (myalgias)
Nausea/vomiting, diarrhea, abdominal pain
Pink eye (conjunctivitis)
Runny nose/nasal congestion without other known cause

Do you have any of the symptoms listed: *

Additional information *

Please describe why 1 or more questions was answered "Yes"

Screening for a second person

Second person's name *

First

Last

Relationship to patient *

Does this person have a confirmed case of COVID-19? *

Has this person been in close contact with a confirmed case of COVID-19 without wearing appropriate PPE? *

Has this person been in close contact with anyone with acute respiratory illness in the past 14 days? *

Has this person travelled outside of Canada in the past 14 days? *

Does this person have any of the following symptoms: *

Fever
New onset of cough
Worsening chronic cough
Shortness of breath
Difficulty breathing
Sore throat
Difficulty swallowing
Decrease or loss of sense of taste/smell
Chills
Headaches
Unexplained fatigue/malaise/muscle aches (myalgias)
Nausea/vomiting, diarrhea, abdominal pain
Pink eye (conjunctivitis)
Runny nose/nasal congestion without other known cause

Does this person have any of the symptoms listed: *

Additional information *

Please describe why 1 or more questions was answered "Yes"

Will a third person be entering the office? *

For example, if you have a 2nd child that also has an appointment.

Please read this!

If this third person is another parent/guardian of the patient, please note that we do discourage this with the current health restrictions in place. Please consider whether it is a requirement for this patient, and if not please change your answer above to "No". Thank you for your understanding.

Screening for a third person

Third person's name *

First

Last

Relationship to patient *

Does this person have a confirmed case of COVID-19? *

Has this person been in close contact with a confirmed case of COVID-19 without wearing appropriate PPE? *

Has this person been in close contact with anyone with acute respiratory illness in the past 14 days? *

Has this person travelled outside of Canada in the past 14 days? *

Does this person have any of the following symptoms: *

Fever
New onset of cough
Worsening chronic cough
Shortness of breath
Difficulty breathing
Sore throat
Difficulty swallowing
Decrease or loss of sense of taste/smell
Chills
Headaches
Unexplained fatigue/malaise/muscle aches (myalgias)
Nausea/vomiting, diarrhea, abdominal pain
Pink eye (conjunctivitis)
Runny nose/nasal congestion without other known cause

Does this person have any of the symptoms listed: *

Additional information *

Please describe why 1 or more questions was answered "Yes"

Comments

Optional information

Is there anything else we should know about the information you've provided here today?

Affirmation

I affirm that the information I have provided above is complete and true, and I understand that providing false information may jeopardize the health of the staff, other patients and the general public. *

Please submit your form

You must click Submit below in order for your forms to be sent to us.

Clinic Hours

Tuesday - Thursday	8am ‑ 5pm
Fridays	8am ‑ 4pm

Need to Phone?

You can reach us at 905‑257‑7111

General Inquiries

Map + Directions

Becoming a Patient

COVID Screening Form

STOP HERE!

Read this!

Screening Questions

Screening Questions

Q&A for "I am the patient"

Do you have any of the following symptoms: *

Q&A for "I am responding on behalf..."

Do you have any of the following symptoms: *

Additional people

Screening for you

Do you have any of the following symptoms: *

Screening for a second person

Does this person have any of the following symptoms: *

Please read this!

Screening for a third person

Does this person have any of the following symptoms: *

Comments

Affirmation

Please submit your form

Clinic Hours

Need to Phone?

Related Pages