Need Help? Call:
647-299-4511
COVID 19 - Screening - 202301
Required Field
Personal Info
First Name
Last Name
Contact Info
Email
COVID Questions
Symptoms: Do you have any of the following?
Fever / Headache / Difficulty Swallowing / Sore Throat / Cough / Difficulty Breathing / Loss of Taste or Smell / Fatigue / Chills / Nausea / Pink Eye / Nasal or Sinus Congestion
Yes
No
Screening
Have you had any changes to your medical history since the initial intake?
Characters:
0
/255
Are you willing to wear a face mask in the clinic and during treatment?
Yes
No
Have you tested positive for COVID-19 in the last 2 weeks?
Yes
No
Have you had close contact with anyone who has COVID-19?
Yes
No
Submit Form
×