Patient Name
During the time of the COVID-19 outbreak and Ontario’s State of Emergency, you need to meet the following criteria to be seen
1. I have NOT been experiencing two (2) or more of the following symptoms of COVID-19 in the last 14 days. Symptoms can include:sore throat, runny nose/sneezing, nasal congestion, hoarse voice, difficulty swallowing, decrease or loss of sense of smell, chills, headaches, unexplained fatigue/malaise, diarrhea, abdominal pain, or nausea/vomiting.
2. If over 65 years of age, I have NOT been experiencing any of the following: delirium, falls, acute functional decline, or worsening of chronic conditions.
3. I have NOT been tested/diagnosed as confirmed case of COVID-19 and/or have NOT been in close contact with anyone with these symptoms, or a confirmed or probable case of COVID-19.
4. I have NOT been in close contact with a person with acute respiratory illness who has been to an impacted area of COVID-19.
5. I have NOT travelled outside of Canada in the last 14 days.
I hereby confirm that the information above is true and agree to proceed with chiropractic care on these bases.
Signature of Patient (or Legal Guardian):
