COVID-19 Consent Form – Club Physio Plus

CLUB PHYSIO PLUS COVID-19 CONSENT FORM

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This form must be completed prior to visiting the clinic EVERY TIME. Club Physio Plus appreciates your co-operation in following the COVID-19 protocols which have been put in place to protect patients, staff and our community. These protocols have been established based on recommendations from the Province of Ontario Health and Safety Association Guidance documents.

Date*

First Name*

Last Name*

Are you currently experiencing any of these symptoms? Choose any/all that apply.

Cough that's new or worsening (continuous, more than usual), Runny or Stuffy Nose (not related to seasonal allergies or other known causes or conditions, Shortness of breath (out of breath, unable to breathe deeply), Extreme tiredness that is unusual (fatigue, lack of energy, Muscle aches (different than usual), Sore throat/Difficulty swallowing, Fever (feeling hot to the touch, a temperature of 37.8° Celsius or higher), Headache (non-injury related, Digestive issues (nausea/vomiting, diarrhea, Lost sense of taste or smell,
YESNO

Have you been in contact with anyone who has tested positive for the COVID-19 virus or experienced the symptoms above within the past 10 days?
YESNO

IF YOU ARE EXPOSED TO COVID FROM A FAMILY MEMBER YOU LIVE WITH OR IF YOU TEST POSITIVE, WE REQUIRE 10 DAYS OF ISOLATION AND BEING COMPLETELY SYMPTOM-FREE FOR 24HRS BEFORE RETURNING TO OUR CLINIC. IF YOU WERE IN CLOSE CONTACT, IT IS 5 DAYS AND ASYMPTOMATIC.

If you have said YES to any of the above questions, please call the clinic you will be attending to clarify what the next step may be.

Mississauga (ORC) 905.822.1823

Oakville 905.337.2122

I hereby acknowledge that the above answers are true to the best of my knowledge. I acknowledge and accept that there is a risk that I could be exposed to COVID-19 while attending Club Physio Plus. I also acknowledge and accept that while receiving services, the therapist may need to be closer than the recommended social distancing guidelines in order to assess and/or treat me. I acknowledge and confirm that I am willing to accept this risk as a condition of attending at Club Physio Plus to receive services from the therapist. In consideration of the therapist agreeing to see me in person at Club Physio Plus, I agree to release the therapist and Club Physio Plus (if applicable), their officers, directors, employees, agents and volunteers (the “Releasees”) from any and all causes of action, claims, demands, requests, damages or any recourse whatsoever in respect of any personal injuries or other damages which may occur or arise as a result of exposure to COVID-19 during my visit to Club Physio Plus and/or through the provision of services to me by the therapist. I do hereby acknowledge and agree that notwithstanding the generality of the foregoing, I declare that I will not commence litigation or otherwise seek to recover damages or other compensation against the Releasees based on any action, claim, demand, request, loss or any recourse whatsoever arising from any potential or actual exposure to COVID-19 while attending at Club Physio Plus and/or through the provision of services to me by the therapist. I further acknowledge that the Releasees can rely on this Release of Liability, Waiver of all Possible Claims and Assumption of Risk as a complete defence to any and all claims, damages, causes of action, or recourse or liability that may arise at any time. I have carefully reviewed this Release of Liability, Waiver of all Possible Claims and Assumption of Risk and acknowledge that I fully understand the terms as set out above. I acknowledge that I am signing this Release of Liability, Waiver of all Possible Claims and Assumption of Risk voluntarily.

Please submit the completed consent to the appropriate clinic prior to your appointment:
PLEASE CLICK THE BOX AND PICK THE CLINIC LOCATION YOU ARE ATTENDING

IF YOUR ANSWERS DISAPPEAR, IT HAS BEEN SUBMITTED SUCCESSFULLY.