COVID-19 Form
Name*
Do you travel outside of Canada in the past 14 days?*
Have you tested positive for COVID-19 or had close contact with a confirmed case of COVID-19 without wearing appropriate PPE?*
Do you have any of the following symptoms?*
• Fever • New onset of cough • Worsening chronic cough • Shortness of breath • Difficulty breathing • Sore throat • Difficulty swallowing • Decrease of loss of sense of taste or smell • Chills • Headaches • Unexplained fatigue/malaise/muscle aches • Nausea/vomiting, diarrhea abdominal pain • Pink eye • Runny nose or nasal congestion without other know cause
Are you in quarantine?*
You understand that if you have the above symptoms, you need to stay at home*
CLINIC COVID 19 POLICY:
• Do not have COVID-19 symptoms and not be tested positive in the last 10 weeks.
• If you were tested positive for COVID-19, please self-isolate for 12 weeks before receiving treatment with the clinic or be tested for COVID-19 again after 14 days of isolating to show proof that your body has fully resolved the infection.
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