COVID-19. Screening. COVID-19. Screening. Please enable JavaScript in your browser to complete this form.Name *FirstLastEmail - if you would like to send yourself a copy of this screening form.EmailConfirm EmailDo you/they have fever or have you/they felt hot or feverish recently (14-21 days)? *YesNoAre you/they having shortness of breath or other difficulties breathing? *YesNoDo you/they have a cough? *YesNoAny other flu-like symptoms, such as gastrointestinal upset, headache or fatigue? *YesNoHave you/they experienced recent loss fo taste or smell? *YesNoAre 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) *YesNoIs your/their age over 60? *YesNoDo you/they have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders? *YesNoSignatureClear SignatureDate / TimeDateTimeEmailSubmit