VIRTUAL WAITING ROOM

PLEASE FILL FORM AND SUBMIT TO ENTER OUR VIRTUAL WAITING ROOM AND WAIT FOR OUR CALL TO COME INTO THE OFFICE FOR YOUR SCHEDULED APPOINTMENT. THE FORM MUST BE SUBMITTED SO WE KNOW YOU ARE HERE. THE ACCOMPANYING PERSON MUST FILL IN THE FORM AS WELL.

COVID-19  - Patient Pre-Screening Questionnaire
Have you been in close contact with anyone with acute respiratory illness in the last 14 days?
Has the patient traveled or been in contact with anyone who has travelled utside Ontario in the past 14 days?
Does the patient have a confirmed case of COVID 19
Does the patient have close contact with a confirmed case of COVID-19
Does patient have fever?
Does the patient have new onset of cough?
Does the patient have a worsening chronic cough?

Does the patient have shortness of breath?
Does the patient have difficulty breath?
Does the patient have a sore throat?
Does the patient have difficulty swallowing?
Has the patient experienced recent loss of taste or smell?
Does the patient have chills?
Does the patient have headaches?
Does the patient have unexplained fatigue/malaise/muscle aches (myalgias)
Does the patient have nausea/vomiting?
Does the patient have diarrhea?
Does the patient have abdominal pain?
Does the patient have pink eye?
Does patient have runny nose/nasal congestion without other known case?
If patient over 70 years ago or older, are they experiencing any of the following symptoms: delirium, unexplained or increased numbers of falls, acute functional decline, or worsening of chronic conditions?
Please check the boxes which apply to the person accompanying the patient to the appointment

Your Signature

Guardians Signature

Virtual Waiting Room

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