covid-prescreener - Dr. Andrew Tortorella 289-271-0021

Patient Name*

First Last

Birthdate*

E-mail Address*

Covid-19 Prescreening Questions

Have you had close contact with anyone with acute respiratory illness or travelled outside of Ontario in the past 14 days?*

Have you tested positive for COVID-19 or had close contact with a confirmed case of COVID-19?*

Do you have any of the following symptoms?*

Signature*

Date of Application*