I understand that COVID-19 has a long incubation period during which the carriers of the virus may not show not show the symptoms and may still be contagious.
 
I understand that :

1. physical distancing of 2 metres may not be possible whilst in the treamtent room receiving services.
2. I will sanitise my hands on entering the treatment room.
3. I will make all attempts to cover my mouth and nose in the event of coughing and/or sneezing and then immediately sterilse my hands
4. I will minimise the touching of common surface/areas
5. I may be unable to proceed with services at ROC if they are deemed unsafe to myself or a staff member
6. I may NOT bring children or anyone else who does not have an appointment into the treatment room.

I confirm that:

1. I am not currently positive for COVID-19
2. I am not waiting for the results of a laboratory test for COVID-19
3. I have not been identified as a contact of someone who has test positive for COVID-19 or been asked to self-isolate by any government agency.
4. I am not in high risk category for increased illness or death from COVID-19, including : diabetes, cardiovascular disease, hypertension, lung disease including moderate to severe asthma, being immunocompromised (including transplant recipient), having active malignancy.
5. I am NOT presenting with any of the following symptoms of COVID-19:

I will immediately notify Ross at ROC if I contract the virus within two weeks following my visit.
 
By signing below, I verify that the information I have provided on this form is truthful and accurate.