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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 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 (myalgia)

  • If child <18 years of age: nausea/vomiting, diarrhea

If this form will not submit, please contact the office directly.

905-862-2228