Carleton Sport Medicine COVID-19 Form, Questionnaire and Consent for Treatment

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COVID-19 Screening Questions and Consent to treatment

First Name *

Last Name *

Date *

YYYY

Carleton Sport Medicine is not equipped for Motor Vehicle Accident (MVA) or Workplace Safety Injury (WSIB) appointments. Please contact your family doctor for an appropriate referral. *

I confirm this is not the result of an MVA or WSIB Injury

This is an injury from either a MVA or WSIB, I will call to cancel my appointment

Required

1. Do you have any of the following new or worsening symptoms or signs? *

New or worsening cough

Shortness of breath

Sore throat

Runny nose, sneezing or nasal congestion (in absence of underlying reasons for symptoms such as seasonal allergies

Hoarse voice

Difficulty swallowing

Nausea/vomiting, diarrhea

Unexplained fatigue/malaise

Chills

Unusual headache

Decreased or lose of sense of taste of smell

Fever

NONE OF THE ABOVE

Required

2. If you have travelled outside Canada within the last 14 days, have you received a negative test result from a PCR (lab) test? (note: you cannot attend your appointment until you have received your negative test results) *

Yes

Not Applicable

3. Have you had close contact with anyone with respiratory illness or a confirmed or probable case of COVID-19? *

Yes

4. Did you wear the required and/or recommended PPE according to the type of duties you were performing (e.g., goggles, gloves, mask and gown or N95 with aerosol generating medical procedures (AGMPs)) when you had close contact with a suspected or confirmed case of COVID-19? *

Yes

Not Applicable

Consent

Consent to treatment at Carleton Sport Medicine

I hereby acknowledge that I have agreed to an in-person appointment with a health practitioner (the “HCP”) at the Carleton Sport Medicine Clinic (the “Facility”).I acknowledge and accept that there is a risk that I could be exposed to COVID-19 while attending at the Facility. I also acknowledge and accept that while receiving services, the HCP may need to be closer than the recommended social distancing guidelines to assess and/or treat me. I acknowledge and confirm that I am willing to accept this risk as a condition of attending at the Facility to receive services from the HCP. As mandated by Ontario Public Health and our governing colleges, we are still recommending virtual appointments whenever possible. Your health and safety continue to be our main priority. Masks are mandatory for all patients entering the clinic, if for any reason, a mask cannot be worn, then we recommend a virtual appointment. In consideration of the HCP agreeing to see me in person at the Facility, I agree to release the HCP and the Facility, their officers, directors, employees, agents and volunteers 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 the Facility and/or through the provision of services to me by the HCP. I further acknowledge that the HCP and Facility 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 asset out above. If you have questions regarding this informed consent, please talk to your HCP. By booking your in person appointment, I understand the information outlined above. *

I consent to treatment

Required

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