Covid-19 Screener

Please fill this form as accurately as possible to the best of your ability to help us treat you.

All patients phone screened prior to scheduling Initial appt

Name :

 Are you experiencing ANY new (or worsening) fever cough, shortness Of breath, sore throat, loss of taste/ smell, or abdominal pain/ diarrhea?

 In the last 14 days, have you had contact with someone with or has confirmed COVID-19 exposure or diagnosis?

 Have you travelled overseas in the past 2 weeks?


We do require that:

  • All patients wear a mask when in the facility
  • Temperature screening will be done for everyone entering our office
  • Gloves be wore at all times when in the facility (we provide gloves)

Are you okay with that?

  • All patients to use hand sanitizer upon entry to the Office
  • All patients need to have a mask on when entering the Office and wear gloves after sanitizing their hands
  • All patients screened upon entry to the Office - verbal screen (see above)
  • Temperature will be taken on entry
  • Every visitor / staff wears a mask and gloves at all times when in the clinic
  • Face shield wore by all staff at all times
  • Staff to self monitor symptoms - temp check every night and 2-3 hours prior to shift
  • Staff exposed to known suspect of COVID-19 wear masks at all the times
  • Social distancing to be practiced amongst staff