Covid-19 Screening Questionnaire

To prevent the spread of COVID-19 and reduce the potential risk of exposure to our staff and patients, we are conducting a simple screening questionnaire.

Your participation is important to help us take precautionary measures to protect you and everyone in this building. Thank you.

If you prefer, we also have a printable version of this form.


Self-Declaration by Patient



Have you experienced any cold or flu-like symptoms in the last 14 days including:



If the answer to any of these questions is YES, then unfortunately, we will be unable to see you for your appointment today. If the answer to all of these is NO, then you can proceed to coming in for your appointment.

Please be advised that we may complete a temperature check when you arrive at the practice.