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

First Name

Last Name

Email *

Phone

Address

City

Province / State

Country

Postal Code / Zip

Please put a checkmark if you...

I have not: tested positive or presumptively positive with the coronavirus or have been identified as a potential carrier of the COVID-19 virus or other communicable illness

I have not: experienced any of the following symptoms:

a) Difficulty breathing
b) Fever
c) Coughing
d) Sore throat

e) Difficulty swallowing
f) Unexplained fatigue
g) Nausea, vomiting
h) Unexplained skin lesions

I have not: been in any location designated as hazardous and/or potentially infected with the coronavirus or other communicable illness as defined by a recognized health or regulatory authority

I have not: been in direct contact with or in the immediate vicinity of any person I know to be carrying the coronavirus or other communicable illness

I AGREE to notify Medical Foot Solutions (by email : milton@medicalfootsolutions.com) of any change in status, including diagnosis with coronavirus and/or quarantine, within thirty (30) days either before or following a procedure performed at Medical Foot Solutions

I WILL, if asked, wear a mask at all times while in the Medical Foot Solutions clinic and I will follow all reasonable protective steps that may be recommended by the Chiropodist, and/or staff.

I have answered the above questions truthfully, and to the best of my knowledge I do not have any symptoms associated with COVID-19.

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

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