Assumption of Risk  I acknowledge and accept that there is a risk that I could be exposed to COVID-19 while at The Doctor's House. I also acknowledge that I may need to be closer than the recommended social distancing guidelines when interacting with their staff on-site. I confirm that I am willing to accept this risk as a condition of attending The Doctor's House.  *

I Agree

Name *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Date *

MM

DD

YYYY

Do You Have A Fever? *

Yes

No

Do you have any of the following signs or symptoms? *

New onset of cough

Worsening chronic cough

Sore throat

Shortness of breath

Difficulty breathing

New loss or decrease in sense of taste and smell

Runny nose or nasal congestion with unknown cause

Chills Headache

Unexplained fatigue, malaise, or muscle aches

Difficulty swallowing

Nausea/ vomiting, diarrhea, abdominal pain

N/A

Have you travelled or have had close contact with anyone who has traveled outside of Canada in the past 14 days? *

Yes

No

Have you had a confirmed case of COVID-19 or had close contact with someone with a confirmed case of COVID-19? *

Yes

No

If you are over the age of 70, are you experiencing any of the following symptoms: delirium, unexplained or increased number of falls, acute functional decline, worsening of chronic conditions? *

Yes

No

N/A