• Grey Facebook Icon
  • Grey Twitter Icon
  • Grey Instagram Icon
  • Grey Facebook Icon
  • Grey Twitter Icon
  • Grey Instagram Icon

Port Perry Covid-19 Health Declaration

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

  • Fever and/or chills

  • New onset of cough / Worsening chronic cough

  • Shortness of breath

If this form cannot be submitted, please call the office directly.

905-982-0399

Port Perry Covid-19 Health Declaration

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

  • Cough or barking cough 

  • Shortness of breath

  • Decrease or loss of sense of taste or smell

  • 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

If this form cannot be submitted, please call the office directly.

905-982-0399