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Uxbridge Covid-19 Health Declaration

How are you feeling today?  Please complete this form no more than 48 BUSINESS 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 will not submit, please contact the office directly.

905-862-2228