COVID 19 Pre-Screening Please complete the COVID-19 Pre-Screening prior to your appointment. Name(Required) First Last Email(Required) Phone(Required)Appointment Date(Required) MM slash DD slash YYYY Do you have fever?(Required) Yes No Have you had fever in the past 14 days?(Required) Yes No Have you had any of the following symptoms in the past 14 days? Cough Sore Throat Shortness of Breath Loss of Taste or Smell Diarrhea or Loose Stool Have you ever tested positive for COVID-19?(Required) Yes No If yes, what is the date of last symptom?(Required) MM slash DD slash YYYY Have you come in close contact with someone who has symptoms of COVID-19, quarantined for COVID-19, or is confirmed positive for COVID-19?(Required) Yes No Please read the statement below and type your name to attest the statement is correct.(Required)I attest that the above information is true and correct. The information you provide is important in managing the risk of COVID-19 transmission. The Infectious Disease Act requires a person who has reason to suspect that he is a case or is a carrier of COVID-19, or has had contact with a person with COVID-19, to act in a responsible manner to not expose other persons to the risk of infection by disease.NameThis field is for validation purposes and should be left unchanged.