Patient Screening Form

Online Patient Screening Form

Please select your primary location
 
Do you/they have fever or have you/they felt hot or feverish recently 
(14-21 days)?
 
Are you/they having shortness of breath or other difficulties breathing?
 
Do you/they have a cough?
 
Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?
 
Have you/they experienced recent loss of taste or smell?
 
Are you/they in contact with any confirmed COVID-19 positive patients?
Patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment.
 
Is your/their age over 60?
 
Do you/they have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?
 
Have you/they traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your location)
 

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