Patient Screening Form

First Name: *

Last Name: *

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 gastronintestinal 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)? *