INFORMED CONSENT FORM

(Novel Coronavirus)

    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:

    Choose one of the following:

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




    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: