DFC COVID Consent Form

COVID Consent Form

Please fill out this form prior to your appointment
Patient's Name*

First NameMiddle NameLast Name
Name 1

First NameLast Name
Relationship

MotherFatherGrandparentAunt/UncleOther
Name 2

First NameLast Name
Relationship

MotherFatherGrandparentAunt/UncleOther
Birth Date

MonthDayYear
Email*

Confirmation Emailexample@example.com
Appointment Date*

MonthDayYear
Date
Did the patient have close contact with anyone with acute respiratory illness or traveled outside of Ontario in the last 14 days?*

YesNo
Does the patient have a confirmed case of COVID-19 or had close contact with a confirmed case of COVID-19?*

YesNo

Do you have any of the following symptoms:

	Yes	No
Fever
New onset of cough
Worsening chronic cough
Shortness of breath
Sore throat
Difficulty swallowing
Decrease or loss of sense of taste or smell
Chills
Headaches
Unexplained fatigue/malaise/muscle aches(myalgias)
Nausea/vomiting, diarrhea, abdominal pain
Pink eye (conjunctivitis)
Runny nose/nasal congestion without other known cause

If you or the patient has experienced any of the above symptoms prior to scheduled appointment and after this form is submitted, I agree to notify the office as soon as possible in order to keep the staff and other patient's safe.*

I Understand
I agree that the patient will be the only person coming into the office (unless they require special assistance) and that the patient will be bringing their own mask or facial covering. I understand that if a parent must accompany the patient that the parent will also wear a mask or facial covering. I also agree that the mask will be worn at all times in the clinic or waiting area unless otherwise instructed. I acknowledge that a screening form must be filled out for each appointment scheduled until further notice.*

I Understand
Any Comments:-
I, the legal guardian of the minor patient named above, acknowledge that the information I have provided is true to the best of my knowledge. Please type your name and provide with your signatures.*
Signature*

Clear
Date

MonthDayYear
Date
Hour MinutesAM/PM Option
Should be Empty: