covid - Ancaster Cardiology

Name *

Email Address *

Phone

Do you Have any of the following new or worsening symptoms or signs? *

No symptomsFever of 37.8C/100F or moreNew or worsening cough including croupShortness of breathDecrease in taste or smellMuscle painExtreme fatigueNausea, vomiting or diarrheaIf you answered yes to any symptom call the office at 905.648.6883 for further assistance

In the last 14 days have you: *

Traveled outside CanadaBeen told to isolate or quarantine by a health care provider or public health unitBeen in close contact with a suspected or confirmed case of COVID-19A memeber of your household has been outside Canada and has been told to isolate/quarantineNone of the aboveIf you answered yes to any of the red icons, please stay home and reschedule your appointment.

In the last 10 days have you tested positive on a PCR, rapid antigen test or home-based self-testing kit? *YesNoIf you answered yes, please notify the office at 905.648.6883 and reschedule your appointment.

I AGREE *I declare all my answers to be true and correct. I understand Ancaster Cardiology will not use this information other than Covid-19 contact tracing purposes.

COVID-19 Screening

Do you Have any of the following new or worsening symptoms or signs? *

In the last 14 days have you: *