COVID-19 Screening

Please complete this form prior to your appointment. If you answer Yes to any of these questions, please contact our office at 902-438-3937 (EYES) to reschedule for a future date.

Are you feeling sick?*
Examples of symptoms include new or worsening cough, headache, weakness, fever, chills, difficulty breathing, sore throat, unexplained fatigue
- Yes
- No
Have you experienced a recent loss of smell or taste?*
- Yes
- No
Have you been advised to self isolate for any reason?*
- Yes
- No
Did you provide care or have close contact with a person with COVID-19 (probable or confirmed) while they were ill?*
- Yes
- No
Name*
First Last
Date of your appointment*
MM slash DD slash YYYY
Phone*
Comments (optional)