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

Please put a checkmark if you...
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 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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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.