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 fatigueYesNoHave you experienced a recent loss of smell or taste?*YesNoHave you travelled outside of PEI in the past 14 days?*YesNoDid you provide care or have close contact with a person with COVID-19 (probable or confirmed) while they were ill?*YesNoName* First Last Date of your appointment* Date Format: MM slash DD slash YYYY Phone*Comments (optional)
