First Name Last Name Phone Address City Province / State Country Postal Code / Zip Email 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: 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 have not: *** (If the patient/person) is over 70: experienced any of the following: falls, acute functional decline, or worsening of a chronic condition. Agreement I AGREE to notify Medical Foot Solutions 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 Agreement 2 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. Agreement 3 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'm Hereby Certify