The Clay Emporium

Patient Pre-Screening Form

271 Old Kingston Road, Toronto, ON M1C 1B4      647-922-7211

Full Name:
Kid's Name:
E-mail:
Phone:
YesNo
Have you had close contact with anyone with acute respiratory illness or travelled outside of Ontario in the past 14 days?
Do you have a confirmed case of Covid19 or had close contact with a confirmed case of Covid-19?

Do you have any of the following symptoms?

YesNo
Fever
New Onset of Cough
Worsening Chronic Cough
Shortness of Breath
Difficulty Breathing
Sore throat
Difficulty Swallowing
Decrease or loss of sense of taste of smell
Chills
Headaches
Unexplained fatigue/malaise/muscle aches (myalgias)
Nausea/vomiting, diarrhea, abdominal cramps (of unknown origin)
Pink eye (conjunctivitis)
Runny nose/nasal congestion without other known cause

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