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 BUSINESS hours before your scheduled appointment.
Check the box if the answer is NO
Fever and/or chills
New onset of cough / Worsening chronic cough
Shortness of breath
Decrease or loss of sense of taste or smell
If adult >18 years of age : unexplained fatigue/lethargy/malaise/muscle aches (mylagia)
If child < 18 years of age : nausea/vomiting, diarrhea
If this form cannot be submitted, please call the office directly.
905-982-0399
Cough or barking cough
Muscle aches or joint pain
Extreme tiredness
Sore throat
Runny or stuffy/congested nose
Headache
Nausea, vomiting and/or diarrhea
You live with someone who is currently isolating because of a positive COVID-19 test
You live with someone who is currently isolating because of COVID-19 symptoms
You live with someone who is isolating while waiting for COVID-19 test results