Health Screening Form

Effective June 11, 2022, Health Directive #1 has been allowed to expire, resulting in the government no longer mandating masks for patients attending community health care centres.

However, Ministry regulations also require that the practitioner ensures the health and well-being of patients and staff while attending the clinic. Therefore, there may be times when Medical Foot Solutions staff will require you to wear a mask to ensure the safety of patients and staff. We do appreciate your cooperation.

The form below has been modified to better reflect the ongoing health concerns that we are currently facing. If you have any symptoms listed below or have been in a hazardous infected area, please reschedule your appointment.

Health Assessment And Declaration Form

Please put a checkmark if you...
a) Difficulty breathing
b) Fever
c) Coughing
d) Sore throat
e) Difficulty swallowing
f) Unexplained fatigue
g) Nausea, vomiting
h) Unexplained skin lesions

I hereby certify, represent and warrant as follows: within the twenty one (21) days immediately preceding the date of this health declaration form,


We want you to know exactly how our service/site works and why we may need your details. Please state that you have read and agreed to these terms before you continue.