COVID19 (coronavirus)

This self declaration form is required by the Ministry of Health and the College of Chiropodists of Ontario to help safeguard the health and safety of the employees of Medical Foot Solutions as well as to help reduce any further outbreak of COVID-19 in the general population.

We are requiring all individuals to fill out this form if they are requesting and receiving podiatric care even if they are not currently in isolation. Please review and sign below:

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 been identified as a potential carrier of the Covid-19 virus or similar communicable illness

I have not: experienced any symptoms commonly associated with the coronavirus:

a) difficulty breathing
b) chest pain
c) fever
d) Coughing

e) sore throat
f) difficulty swallowing
g) decrease/loss of taste
h) headaches

i) unexplained fatigue
j) Nausea, vomiting
k) pink eye
l) explained runny nose/sneezing

I have not: been in any location positively designated as hazardous and/or potentially infected with the coronavirus by recognized health or regulatory authority, such as a country for which the government has issued a travel advisory for corona

I have not: been in direct contact with or the immediate vicinity of any person I knew and/or know to be carrying the coronavirus or has been identified as a potential carrier of the coronavirus

I have not: Travelled outside of Ontario in the last 14 days

I am under 70 years of age and if I am over 70 years of age, I have not: experienced any of the following: falls, acute functional decline, or worsening of a chronic condition.

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,

1	Home page
2	Search Form
3	Log in
4	Sign Up
5	Blog
6	Team
7	Portfolio
8	Contact us
9	FAQ
0	Access key details

COVID19 (coronavirus)

Health Assessment And Declaration Form

About Us

Contact Us

Stay in touch

Book an appointment

Access key details