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Optometrist At Holly & Derry in Milton, ON

Call 905-876-0044
Schedule An Eye Exam
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Home » Contact Us » Patient Registration Form » Covid-19 Declaration

Covid-19 Declaration

  • I declare that I do not have any of the following symptoms

    • Fever(feeling hot to the touch, a temperature of 37.8 degrees Celsius or higher)
    • Chills
    • Cough that's new or worsening(continuous, more than usual)
    • Barking cough, making a whistling noise when breathing(croup)
    • Shortness of breath(out of breath, unable to breathe deeply)
    • Sore throat
    • Difficulty swallowing
    • Runny nose(not related to seasonal allergies or other known causes or conditions)
    • Stuffy or congested nose(not related to seasonal allergies or other known causes or conditions)
    • Lost sense of taste or smell
    • Pink eye(conjunctivitis)
    • Headache
    • Digestive issues(nausea/vomiting, diarrhea, stomach pain)
    • Muscle aches
    • Extreme tiredness that is unusual(fatigue, lack of energy)
    • Falling down often
    • For young children and infants: sluggishness or lack of appetite
  • Date Format: MM slash DD slash YYYY

Please make sure to click on the submit button on this page, as well as on the patient registration form