COVID-19 Screening Form for current patients
Please only use this form if you are a current patients, new patients need to use our New Patient Form.
Welcome to Our Office. Your overall health is important to us. We strive to treat all patients in a safe and effective manner and need to ask some detailed questions related to your general
Private & Confidential Health History and Personal Information
COVID-19 Screening Question
We are required by our Regulating body to screen you for COVID-19. Please answer the following to the best of your knowledge.
Q2: Do you have any of the following symptoms?
This is the last section. Note that you will not be able to go back after clicking [Next]. Please ensure that the information you provided is accurate to the best of your knowledge.
More information about the regulations can be found at:
Please click Submit to send us your information
Thank you for taking the time to complete this form prior to your appointment. The welfare of our patients and our staff is of the utmost importance to us your cooperation is helping us address the health needs during these challenging times.