COVID-19 Self Declaration Form
For the health and safety of our staff and clients, declaration of illness is required. Be sure that the information you'll give is accurate and complete. Please get immediate medical attention if you have any of the COVID-19 signs.
Name
*
First Name
Last Name
Email or phone number:
*
Have you travelled outside of Canada during in the last 30 days?
*
Yes
No
If so, have you self isolated for the required 14 days? If you answer "No" to the below question you may attend examinations until you have self isolated for 14 days and are symptom free.
*
Yes
No
Did not travel
Dates of travel
Arrival and return dates for each area
In the past 14 days, have you been in contact with people being infected, suspected or diagnosed with COVID-19? If you answer "Yes" to the below question you may not be able attend examinations until you have self isolated for 14 days and are symptom free.
*
Yes
No
Please state whether you've experienced/are experiencing the following. If you answer "Yes" to any of the below questions you may not be able to attend examinations until the symptoms have cleared and you have self isolated for 14 days and are symptom free.
*
Yes
No
Fever
New or Worsening Cough
Shortness of Breath
Persistent Pain in the Chest
Persistent Headache
Sore Throat
Runny, Stuffy, Congested Nose (not related to allergies)
Extreme Fatigue or Tiredness
For the safety of our staff and clients face coverings are required when attending our office unless you have a genuine health condition preventing you from wearing one. Although we prefer you bring your own face covering, we have them at the office in case you forget. Please acknowledge that you have read the above paragraph.
*
Please Select
Yes
I acknowledge that the information I've given is accurate and complete.
Date
*
-
Month
-
Day
Year
Date
Signature
*
Submit
Should be Empty: