Name *

First Name

Last Name

Contact Phone Number *

(###)

###

####

Have you, or has anyone in your household, travelled outside of Ontario within the last 14 days? *

Yes

No

Have you, or has anyone in your household, been in close contact (less than 6 feet without PPE) with anyone suspected or with a confirmed case of COVID-19 in the last 14 days? *

Yes

No

Have you, or anyone in your household, experience or are currently experiencing any of the following symptoms? Check ANY and ALL that apply. *

Fever or feverish (feeling hot to the touch, a temperature of 37.8 degrees Celsius or higher)

Sore throat

New cough or worsening cough

Barking cough, making a whistling noise when breathing (croup)

Chills

Muscle aches

Shortness of breath (out of breath, unable to breathe deeply)

Difficulty swallowing

New loss of smell

New loss of taste

Runny nose (not related to seasonal allergies)

Stuffy or congested nose (not related to seasonal allergies)

Pink eye (conjunctivitis)

Headache

Digestive issues (nausea/vomiting, diarrhea, stomach pain)

Extreme tiredness that is unusual (fatigue, lack of energy)

Falling down often

For young children and infants: sluggishness or lack of appetite

None of the above

Declaration: I confirm that the information above is correct to the best of my knowledge. I understand that my appointment may be rescheduled. I further understand that I may need to contact my doctor, Telehealth or Halton Region Public Health; and I may be referred for COVID-19 testing. *

Yes

No

I would like to speak with an Oakville Eye Care Team member