Form
On the day of your appointment:
1.
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Please call and reschedule your appointment if you are experiencing any flu-like symptoms or have traveled outside of Canada in the previous 14 days.
2.
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When you enter the clinic, it is mandatory that you put on a mask and sanitize your hands. Please bring a mask from home.
3.
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Our front desk staff will check you in for your appointment and then you will proceed to the waiting area as normal to wait for your naturopathic doctor to come get you. All waiting room chairs are 6 feet apart.
4.
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You are asked to attend your appointments unaccompanied if possible.
Cancellations, Late Arrivals, and No-Show Policy:
1.
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Our current 24 hour cancellation policy will remain the same.
2.
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If you are late for your appointment, there is a chance we will LATE CANCEL your appointment. Late cancellations and late arrivals will incur the full cost of the original appointment.
Risk Assessment
Screening questionnaire
Do you have any of the following symptoms which are new or worsened if associated with allergies, chronic or preexisting conditions: fever, cough, shortness of breath, difficulty breathing, sore throat, and/or runny nose?
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Yes
No
Have you returned to Canada from outside the country (including USA) in the past 14 days?
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Yes
No
In the past 14 days, at work or elsewhere, while not wearing personal protective equipment:
Did you have close contact with a person who has a probable or confirmed case of COVID-19?
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Yes
No
Did you have close contact with a person who had an acute respiratory illness that started within 14-days of their close contact to someone probable or confirmed case of COVID-19?
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Yes
No
Did you have close contact with a person who had an acute respiratory illness who returned from travel outside of Canada in the 14 days before they became sick?
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Yes
No
Did you have a laboratory exposure to biological material (i.e. primary clinical specimens, virus culture isolates) known to contain COVID-19?
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Yes
No
If you answered "YES" to any of the above, you are not permitted to attend your session at our clinic and must self isolate.
Client Name
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First Name
Last Name
Parent/Guardian (If client is under 18 years of age)
First Name
Last Name
Signature of Client (18+) or Parent/Guardian (Client under 18)
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Clear
Submit
Should be Empty: