Lakepoint Medical Clinic
COVID-19
Patient Screening & Treatment Consent Form
Patient Name
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First
Last
Date of birth
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YYYY dash MM dash DD
Are you fully vaccinated for Covid-19?
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An individual is considered fully vaccinated if it has been more than 2 weeks since they received the last shot of a 2-dose vaccine (for example, Moderna or Pfizer) or a single dose vaccine (J&J).
Yes
No
Do you have a fever or have felt hot or feverish anytime in the last two weeks?
*
Yes
No
Do you have any of the following symptoms:
Dry cough
Shortness of breath
Difficulty breathing
Sore throat
Runny nose
Cough that’s new or worsening
Difficulty swallowing
Stuffy or congested nose
Pink eye
Digestive issues
Muscle aches
Falling down often
Extreme tiredness that is unusual
Headache that is unusual or long lasting headache
For young children and infants: sluggishness or lack of appetite
Have you experienced a recent loss of smell or taste?
*
Yes
No
Have you been in contact with any confirmed COVID-19 positive patients, or person self-isolating because of a determined risk for COVID-19?
*
Yes
No
Have you returned from travel outside of Canada in the last 14 days?
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Yes
No
Are you over the age of 60?
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Yes
No
Do you have any of the following conditions?
Heart disease
Lung disease
Kidney disease diabetes
Auto-immune disorder
Consent
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I understand the novel coronavirus causes the disease known as COVID-19 and that it is currently a pandemic. I understand the novel coronavirus has a long incubation period during which carries of the virus may not show symptoms and still be contagious. For this reason, it is recommended to stay home and avoid close contact with other people when at all possible.
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Consent
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I understand that due to the visits of other patients, the characteristics of the novel coronavirus, and the characteristics of the medical procedures, that I have an elevated risk of contracting AND SPREADING the novel coronavirus simply by being in the medical office.
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Consent
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I understand the federal and provincial governments have asked individuals to maintain social distancing of at least 2 meters (6 feet) and I recognize it is not possible to maintain this distance while receiving medical treatment.
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Consent
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I confirm that I do NOT have any TWO or MORE of the following symptoms of COVID-19: fever, new or worsening cough, sore throat runny nose or headache.
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Consent
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I confirm that I have NOT tested POSITIVE for COVID-19.
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Consent
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I confirm that I am not waiting for the results of a test for COVID-19.
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Consent
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I confirm that this is not currently a period where I required to self-isolate for 14 days.
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Consent
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I verify that the information I have provided on this form is truthful and accurate. I knowingly and willingly consent to have medical treatment completed during the COVID-19 pandemic.
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Signature
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Name
This field is for validation purposes and should be left unchanged.
Lakepoint Medical Clinic
#202-525 Highway 97 South
West Kelowna, BC V1Z 4C9
ph: (778) 755-0700 fax: (778) 755-0705
[email protected]