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 be aware that any individual who answers ‘YES’ to ANY of the questions below will not be permitted to attend our office for at least 14 days and is directed to take appropriate action for Positive Screening Results.

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


PERSONAL INFORMATION


New ClientExisting Client


COVID-19 REGULAR SCREENING QUESTIONS



YesNo


YesNo


YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo


YesNo

       
        YesNo
        YesNo
        YesNo
        YesNo


CONSENT


If you answered ‘YES’ to ANY of the questions above, you are not be permitted to attend our office for at least 14 days and should take appropriate action for Positive Screening Results.
Chiropractors are not permitted to attempt a differential diagnosis of clients who present signs and symptoms of COVID-19.