COVID-19 Screening Form

As required by the Provincial Health Officer and the College of Chiropractors of Ontario, all clients should complete an active screening process prior to booking and/or arrival for an appointment.

Please complete the form below to help us serve you better.


    PERSONAL INFORMATION


    New ClientExisting Client


    COVID-19 SCREENING QUESTIONS



    YesNo
    YesNo
    YesNo
    YesNo
    YesNo
    YesNo

    Positive COVID-19 Screening
    Because you have one or more of these symptoms of COVID-19, you are not permitted to attend our office for at least 14 days and should take appropriate action for Positive Screening Results.


    YesNo

    Positive COVID-19 Screening
    Because you have answered 'YES' to Q2, you are not permitted to attend our office until your isolation period is over.


    YesNo


    YesNo

    Positive COVID-19 Screening
    Because you have answered 'NO' to Q3 and 'YES' to Q4, you are not permitted to attend our office until 14 days after your return to Canada.


    YesNo

    Positive COVID-19 Screening
    Because you have answered 'NO' to Q3 and 'YES' to Q5, you are not permitted to attend our office until 10 days after your exposure to a confirmed case of COVID-19.
    For further information, please see the Government of Ontario's High Risk Contact Flow Chart.

    You have PASSED our COVID-19 Screening!
    You are ready to proceed with your appointment.


    CONSENT


    Chiropractors are not permitted to attempt a differential diagnosis of clients who present signs and symptoms of COVID-19.