I,

knowingly and willingly consent to receive treatments and/or assessments completed at this clinic during the COVID-19 pandemic.

Please check off each box in acknowledgement of each applicable statement:

I confirm that I am not presenting any symptoms of COVID-19 which are identified by the Public Health Agency of Canada.

I understand that due to the frequency of visits of other patients, the characteristics of the novel coronavirus, and the characteristics of medical procedures, that I have an elevated risk of contracting the novel coronavirus simply by being in a clinic.

I understand that the Public Health Agency of Canada has asked individuals to maintain physical distancing of at least 2 meters (6 feet) to prevent the spread of the novel coronavirus and that it not possible to maintain this distance during my procedure which may by increasing my risk

Choose one of the following:
I am under 65 with no pre existing health conditions for the novel coronavirus.I am over 65 and I am aware pre-existing health conditions make one vulnerable to the novel coronavirus which include: diabetes, heart disease, lung disease, kidney disease, or any auto-immune disorder.

I confirm that I am not presenting any of the following symptoms of COVID-19 identified by the Public Health Agency of Canada:

Fever > 38°C
Sore throat
Shortness of breath
Flu-like symptoms

I confirm that I am not currently positive for the novel coronavirus.

I confirm that I am not waiting for the results of a laboratory test for the novel coronavirus.

I verify that I have not returned from any country outside of Canada in the last fourteen (14) days.

I understand that the treatment I am receiving today is considered non-emergency health care, and I am choosing to proceed anyways.

BY AFFIXING MY SIGNATURE BELOW, I CERTIFY THAT:

1. I have read and fully understand the contents of this informed consent form and the nature and extent of COVID-19.
2. I verify that the information I have provided on this form is truthful and accurate. I knowingly and willingly consent to receive treatments at the Pioneers Ergonomic clinic during the COVID-19 pandemic.

Electronic Signature:
Email to Send Confirmation: