COVID-19 Medical Patient Screening & Consent | Preview

COVID-19

Patient Screening & Treatment Consent Form
Patient Name*
First Last
Date of birth*
YYYY dash MM dash DD
Are you fully vaccinated for Covid-19?*
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?*
- Yes
- No
Are you over the age of 60?*
- Yes
- No
Do you have any of the following conditions?
- Heart disease
- Lung disease
- Kidney disease diabetes
- Auto-immune disorder
Consent*
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.*
Consent*
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.*
Consent*
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.*
Consent*
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.*
Consent*
I confirm that I have NOT tested POSITIVE for COVID-19.*
Consent*
I confirm that I am not waiting for the results of a test for COVID-19.*
Consent*
I confirm that this is not currently a period where I required to self-isolate for 14 days.*
Consent*
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.*
Signature*
Phone
This field is for validation purposes and should be left unchanged.

COVID-19

Patient Screening & Treatment Consent Form