Port Perry: 905-982-0399
Uxbridge: 905-862-2228
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How are you feeling today? Please complete this form no more than 48 hours before your scheduled appointment.
Fever
New onset of cough / Worsening chronic cough
Shortness of breath / Difficulty breathing
Sore throat / Difficulty swallowing
Decrease or loss of sense of taste or smell
Chills, headache, or unexplained fatigue
Nausea, vomiting, diarrhea, abdominal pain
Muscle aches
Pink Eye (conjuntivitis)
Runny Nose / Nasal congestion
If this form cannot be submitted, please call the office directly.
905-982-0399