To keep our patients and team as safe as possible, we ask that you print and complete this form, and bring with you to your appointment.

  1. Have you received the final (second) dose of COVID-19 vaccine more than 14 days ago?
  2. Have you had close contact with a person with a confirmed case of COVID-19 without wearing appropriate PPE?
  3. Do you have any of the following symptoms:
    • Fever, chills, headache, sore throat
    • New onset of cough
    • New onset or worsening chronic cough
    • Decreased or loss of sense of taste or smell
    • Adults 18 years and over:
      Unexplained fatigue/lethargy/malaise or muscle ache (myalgia)
    • Under 18 years old:
      Nausea/vomiting/diarrhea
  4. Have you tested POSITIVE for COVID-19 in the past 10 days or have you been told to self-isolate?
    Please answer questions 5 and 6 only if you are NOT fully vaccinated (answered NO to question 1)
  5. Have you travelled outside of Canada in the past 14 days?
  6. Have you had close contact with a person with a confirmed case of COVID-19 without wearing appropriate PPE?

If you answer “NO” to all the questions¬†(except for question 1), ¬†you may make an appointment at our office.
If you answer “YES” to any of the questions¬†(except for question 1), please see your doctor to determine if you are COVID-19 positive. COVID-19 positive or potentially positive patients will be seen for EMERGENCY procedures only.

We thank you for your patience and understanding.