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Dr. J. Deol & Associates Family Eye Care
Dateof appointment
date_range
Gender:
Last Name
First Name
Referral:
Health Card No
Date of Birth:of appointment
date_range
Health Card Expiry:of appointment
date_range
Address:your full name
City:your full name
Postal code:your full name
Occupation:your full name
Home Ph:your full name
Name of Family Doctor:your full name
Cell Ph:your full name
Phone# of Family Doctor:your full name
What is the reason for your visit today?
Other reason for your visit today?your full name
Medical Conditions:
Other Medical Conditions:your full name
We do direct billing to insurance companies
Name of Insurance company:your full name
Policy Number:your full name
Member Id:your full name
Name of the Primary policyholder:your full name
Date of Birth:of appointment
date_range
Pre-appointment screening for COVID-19:
1. Do you have a fever or have felt hot or feverish anytime in the last two weeks (14 days)?
2. Do you have any of the following symptoms:
Dry cough?
Shortness of breath?
Difficulty breathing?
Sore throat?
Runny nose?
Diarrhea ?
3. Does anyone in your household have any of the above symptoms ?
4. Have you experienced a recent loss of smell or taste?
5. Have you been in contact with any covid 19 +ve patients, or persons self isolating because of a risk for COVID-19?
6. Have you returned from travel outside of Canada in the last 14 days?
7. Have you returned from travel within Canada from a location known affected with COVID-19?
I am verifying that all the above statements are true.
Please type your initials:
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