Covid-19 Form

Understand that the federal and provincial authorities have recommended that Ontarians stay home and avoid close contact with other people when at all possible. (Initial) *

I understand the federal and provincial authorities have asked individuals to maintain social distancing of at least a two (2) meters (six (6) feet) and I recognize it is impossible to maintain this distance while receiving medical treatment. (Initial) *

I understand that due to the visits of other patients, the characteristics of the novel coronavirus, and the characteristics of medical procedures, that I have an elevated risk of contracting the novel coronavirus simply by being in the doctor’s office. (Initial) *

I agree to complete a COVID-19 screening questionnaire as required by the Ministry of Health. (Initial) *

I confirm that I am not waiting for the results of a test for COVID-19. (Initial) *

I confirm that this is not currently a period during which public health authorities required I self-isolate for 14 days. (Initial) *

I verify that the information provided on this form is truthful and complete. I knowingly and willingly consent to receiving medical treatment for myself and/or my child during the COVID-19 pandemic. *
Type your acknowledgment/consent statement or initials here