Patient Screening Form

Patient Name*

First Last

Phone*

Email*

Do you/they have fever or have you/they felt hot or feverish recently (14-21 days)?*

Are you/they having shortness of breath or other difficulties breathing?*

Do you/they have a cough?*

Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?*

Have you/they experienced recent loss of taste or smell?*

Are you/they in contact with any confirmed COVID-19 positive patients?*

Patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment.

Is your/their age over 60?*

Do you/they have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?*

Have you/they traveled in the past 14 days to any regions affected by COVID-19? (as relevant to your location)*