Covid-19 Form

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Patient Acknowledgement: COVID-19 Pandemic Risk

Please read the acknowledgement below. Initial/sign all areas indicated (electronically accepted) Please complete one per patient

Location of Appointment*

Markham

Scarborough

North York

I understand that the novel coronavirus causes the disease known as COVID-19 and that it is currently a pandemic. I understand that the novel coronavirus virus has a long incubation period during which carriers of the virus may not show symptoms and still be contagious. For this reason, I 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 a least 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)*

If I or my child received COVID-19 test results in the past two weeks, the last results I received were negative (initial)*

If applicable, approximate date of test: *

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.

SIGNATURE OF PATIENT OR PARENT/GUARDIAN:

Date ×

Name of Patient or Child Being Seen: *

Date of Birth*

Select Date ×

Health Card*

Health Card

Covid-19 Form

Please read the acknowledgement below. Initial/sign all areas indicated (electronically accepted) Please complete one per patient

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.

SIGNATURE OF PATIENT OR PARENT/GUARDIAN:

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