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We're in Brampton, on Mississauga Road at Financial Drive, just north of Steeles Ave W

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Home » Contact Us » COVID-19 Questionnaire Form

COVID-19 Questionnaire Form

Please answer all of the following questions:
Are you currently experiencing one or more of the symptoms below that are new or worsening? Symptoms should not be chronic or related to other known causes or conditions:
Fevers and/or chills
Cough
Sore Throat
Shortness of breath
Loss of smell/taste
Gastrointestinal symptoms (abdominal pain, diarrhea, vomiting)
Pink Eye
Or other cold like symptoms (runny/stuffy nose)?
In the last 14 days, have you travelled outside of Canada AND been advised to quarantine (as per the federal quarantine requirements)?(Required)
Is anyone you live with currently experiencing any new COVID-19 symptoms and/or waiting for test results after experiencing symptoms?(Required)
In the last 14 days, has someone in your household (someone you live with), travelled outside of Canada AND has been advised to quarantine (as per the federal quarantine requirements)?(Required)
Has a doctor, health care provider or public health unit advised you that you should be currently isolating (staying at home)?(Required)
In the last 10 days, have you been identified as a “close contact” of someone who currently has COVID-19?(Required)
In the last 10 days, has someone in your household (someone you live with), been identified as a “close contact” of someone who currently has COVID 19 AND been advised by a doctor, health care provider or public health unit to self-isolate?(Required)
In the last 10 days, have you received a COVID Alert exposure notification on your cell phone?(Required)
In the last 10 days, have you tested positive on a rapid antigen test or a home-based self-testing kit?(Required)
If you answered yes to any of the 9 questions above, you will be asked to please kindly reschedule your appointment for after 14 days. This is to further adhere to the safety compliance from the Ministry of Health and our College of Optometry, for all our patients, staff and doctors.

Our office is taking strict precautions to limit any potential exposure to COVID-19 by sanitizing and disinfecting areas such as doorknobs, waiting room chairs, equipment, exam rooms, frames, restrooms etc, after each patient. All of our staff and doctors will be wearing personal protective equipment as well.

We ask that you please kindly wear a mask to your appointment. If you do not have one, you may purchase a mask at our office once you arrive. You will be asked to wash your hands or use sanitizer once you arrive as well.

Please sign below that you have answered all the questions to the best of your knowledge and understand our office safety protocols.
Name(Required)
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