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Covid-19 Screening Form

For ALL IN-CLINIC Patients and Visitors, It is required to fill out this screening questionnaire for EACH VISIT to the clinic.

COVID-19 Screening Form
  • Please Carefully read and answer ALL following questions:

  • If you answer “YES” to any of above questions, we ask you to :

    Please call the clinic and cancel your "in person" appointment and discuss other treatment options. Call your primary care provider or Telehealth Ontario at 1-866-797-0000 or Public Health Ottawa at 613-580-6744 for further clinical assessment.

    Declaration:
    1. I have answered all the above questions honestly and truthfully. Please call our clinic and cancel your in person appointment. We will be happy to provide you treatment through telerehab.
    2. By signing below, I consent and accept the inherent risks of in-person physiotherapy treatment in light of the COVID-19 Pandemic and any potential exposure that occurs as a result.

  • This field is for validation purposes and should be left unchanged.
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