COVID-19 Pre-screening and Informed Consent Form

THE COMPLETION OF THIS FORM IS REQUIRED 12 HOURS PRIOR TO RECEIVING YOUR TREATMENT.

As mandated, prior to your appointment you must complete a 2 step informed consent and screening process.

This online form submission is the preliminary informed consent and COVID-19 prescreen that is required to be received no sooner than 12 hours of your appointment time. If you submit this form earlier than 12 hours from your scheduled appointment time, you will be required to resubmit at the time of treatment.

If you pass the initial screening, your second pre-screening will occur once you have arrived at the office.

If you have any questions, give us a call at 519-325-0118.

It is important to note, that this form submission will be kept on file for 10 years as mandated by the College of Massage Therapists of Ontario.

Full Name

Phone Number

Date of Birth (MM/DD/YY)

I understand the novel coronavirus causes the disease known as COVID-19: I understand the novel coronavirus causes the disease known as COVID-19: YES NO

I understand the novel coronavirus has a long incubation period during which carriers of the virus may not show symptoms and still be contagious: I understand the novel coronavirus has a long incubation period during which carriers of the virus may not show symptoms and still be contagious: YES NO

I verify that I have NOT had a confirmed case of COVID-19: I verify that I have NOT had a confirmed case of COVID-19: YES NO

I verify that I have NOT had close contact with a confirmed case of COVID-19 without wearing appropriate PPE: I verify that I have NOT had close contact with a confirmed case of COVID-19 without wearing appropriate PPE: YES NO

I verify that I have NOT been identified as a contact of someone who has tested positive for novel coronavirus or been asked to self isolate by Ontario Health, the Communicable Disease Control or any other government health agency: I verify that I have NOT been identified as a contact of someone who has tested positive for novel coronavirus or been asked to self isolate by Ontario Health, the Communicable Disease Control or any other government health agency: YES NO

I verify that I have NOT traveled outside of Ontario whether by car, air, bus or train in the past 14 days: I verify that I have NOT traveled outside of Ontario whether by car, air, bus or train in the past 14 days: YES NO

I understand that any travel from any country outside of Canada including travel by car, air, bus or train significantly increases my risk of contracting and transmitting the novel coronavirus. Ontario Health Services require self isolation for 14 days from the date a person has returned to Canada: I understand that any travel from any country outside of Canada including travel by car, air, bus or train significantly increases my risk of contracting and transmitting the novel coronavirus. Ontario Health Services require self isolation for 14 days from the date a person has returned to Canada: YES NO

I understand that Ontario Health Services has asked individuals to maintain social distancing of at least 2m and I understand that during a massage treatment/naturopathic session that social distancing is not possible: I understand that Ontario Health Services has asked individuals to maintain social distancing of at least 2m and I understand that during a massage treatment/naturopathic session that social distancing is not possible: YES NO

I am NOT currently positive for the novel coronavirus: I am NOT currently positive for the novel coronavirus: YES NO

I confirm I am NOT waiting for laboratory test results for the novel coronavirus: I confirm I am NOT waiting for laboratory test results for the novel coronavirus: YES NO

I verify that I do NOT have any of the following symptoms of COVID-19 identified by Ontario Health Services, which are new or worsened, if associated with previously diagnosed allergies, chronic or pre-existing conditions, within the last 14 days: Fever, New onset of cough, Worsening chronic cough, Shortness of breath, Difficulty breathing, Sore throat, Difficulty swallowing, Decrease or loss of sense of taste or smell, Chills, Unexplained fatigue/malaise/muscle aches (myalgias), Nausea/vomiting, diarrhea, abdominal pain, Pink eye (conjunctivitis), Runny nose/nasal congestion without other known cause: I verify that I do NOT have any of the following symptoms of COVID-19 identified by Ontario Health Services, which are new or worsened, if associated with previously diagnosed allergies, chronic or pre-existing conditions, within the last 14 days: Fever, New onset of cough, Worsening chronic cough, Shortness of breath, Difficulty breathing, Sore throat, Difficulty swallowing, Decrease or loss of sense of taste or smell, Chills, Unexplained fatigue/malaise/muscle aches (myalgias), Nausea/vomiting, diarrhea, abdominal pain, Pink eye (conjunctivitis), Runny nose/nasal congestion without other known cause: YES NO

For patients over 70 years of age: I verify that I am NOT experiencing any of the following symptoms: delirium, unexplained or increased number of falls, acute functional decline, or worsening of chronic conditions (if not applicable, please answer YES): For patients over 70 years of age: I verify that I am NOT experiencing any of the following symptoms: delirium, unexplained or increased number of falls, acute functional decline, or worsening of chronic conditions (if not applicable, please answer YES): YES NO

I verify the information that I have provided on this form is truthful and accurate: I verify the information that I have provided on this form is truthful and accurate: YES NO

I knowingly and willingly consent to have a massage therapy treatment or naturopathic session at this time: I knowingly and willingly consent to have a massage therapy treatment or naturopathic session at this time: YES NO

11 + 3 =