If you are not feeling well in ANY way (this includes sinus congestion, cold symptoms, flu symptoms etc.) please let our office know. Even if it is not COVID we would appreciate if you could reschedule your appointment. If our staff gets sick we cannot treat our patients for an extended period of time and this significantly affects us and the rest of our client base.

This screening tool is mandated by the province of Ontario and the ministry of health throughout the health and emergency response system . Ensuring all health providers are following the same screening protocol will help ensure consistency when dealing with suspected or confirmed cases of COVID-19. We thank you for completing this form in full and helping us to keep our patients and staff healthy so that we can remain open to help you. This form must be submitted prior to attending your appointment in person.

COVID-19 screening tool

First Name *

Last Name *

Email *

Have you tested positive for COVID 19 in the past 10 days or have you been told you should be self isolating?

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

Are you feeling unwell in any way not related to the reason for your visit? (sore throat, congestion, runny nose, fever or chills, nausea, vomiting etc.)

I understand that I should reschedule my appointment if I am feeling unwell (out of respect for our staff and other patients) EVEN IF I AM COVID NEGATIVE. Anyone who is sick or has any symptoms of illness, including those not listed in this screening tool, should stay home and seek assessment from a health care provider if needed.

I understand that sending this form back will confirm my appointment. Cancellations require 24 hours notice or a no show fee will apply.

These questions are mandated by the province of Ontario. We appreciate your compliance. Your appointment will not be confirmed until this form is received.

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25 Stonebridge Blvd, unit 2

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(705) 422-0224

COVID-19 screening tool

Thank you for completing this screening tool. Your appointment is now confirmed. We will contact you if we need to reschedule your appointment based on your answers.

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