Online Appointment Pre-screening for Corona

Please complete the form below to confirm your appointment.

Patient Name*

Email address*

Phone Number*

Is this appointment for you?*

Yes

No

What is your name and relationship to patient?*

Do you have fever or have experienced fever within the past 14-21 days?*

Yes

No

Are you having shortness of breath or other difficulties breathing?*

Yes

No

Do you have a cough?*

Yes

No

Do you have any flu-like symptoms, such as gastrointestinal upset, headache, runny nose, tiredness, fatigue?*

Yes

No

Have you experience recent loss of taste or smell?*

Yes

No

Have you come into contact with a patient with any confirmed COVID-19 patient?*

Yes

No

Is your age over 60?*

Yes

No

Do you have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?*

Yes

No

Have you traveled in the past 14 days to any regions affected by COVID-19?*

Yes

No

By clicking this box, I certify all the information above is true and correct to the best of my knowledge.*

I agree

Pre-appointment Screening