CLUB PHYSIO PLUS COVID-19 CONSENT FORM

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.




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

YESNO


YESNO


YESNO


YESNO


YESNO


YESNO


YESNO


YESNO


YESNO


YESNO


YESNO


YESNO


YESNO


YESNO


YESNO


YESNO


YESNO


YESNO


YESNO


YESNON/A

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.
ORC 905.822.1832
Oakville 905.337.2122
Port Credit 905.274.1035