Pre-Appointment COVID Screening

*Please fill in this form no more than ONE day prior to coming into the clinic*

Do you have any of the following symptoms?
Have you or anyone you have been in contact with travelled outside of the country in the past 14 days?
Are you awaiting a COVID test or have you tested positive for COVID-19?

By pressing submit, I as the patient or patient's guardian state that I have, to the best of my ability, answered these questions truthfully and accurately. 

Thanks for submitting!