Home
Services
Physiotherapy
Pelvic Floor Physiotherapy
Sports Injuries
Pre/Post Surgical Rehabilitation
Custom Foot Orthotics
Neuropathy
Massage Therapy
Orthopaedic Manual Therapy
Chiropractic care
Chiropody foot care
Medical Acupuncture
Active Exercise Program
Home Care Physiotherapy
Fall Risk Assessment and Treatment
Intramuscular Stimulation (IMS)
Mobility Aids Assessment and Prescription
Bracing
About
About
Team
Testimonials
Insurance Companies
FAQ
Patients
GLA:D Program
Blog
Contact
Forms
Consent Form
Appointment Requests
COVID Form
Safety
Home
Home
Services
Physiotherapy
Pelvic Floor Physiotherapy
Sports Injuries
Pre/Post Surgical Rehabilitation
Custom Foot Orthotics
Neuropathy
Massage Therapy
Orthopaedic Manual Therapy
Chiropractic care
Chiropody foot care
Medical Acupuncture
Active Exercise Program
Home Care Physiotherapy
Fall Risk Assessment and Treatment
Intramuscular Stimulation (IMS)
Mobility Aids Assessment and Prescription
Bracing
About
About
Team
Testimonials
Insurance Companies
FAQ
Patients
GLA:D Program
Blog
Contact
Forms
Consent Form
Appointment Requests
COVID Form
Safety
COVID Form - Richmond Hill Physiotherapy, Sports, Massage RMT, Pain Relief, Injuries & Rehabilitation
Home
COVID Form
For ALL IN-CLINIC Patients, It is required to fill out this screening questionnaire for EACH VISIT to the clinic
For ALL IN-CLINIC Patients, It is required to fill out this screening questionnaire for EACH VISIT to the clinic
Please Carefully read and answer ALL following questions:
1 – Have you, or anyone in your house, travelled internationally or out of province within the past 2 weeks?
Yes
No
2- Have you been in contact with anyone in the past 2 weeks that has tested positive for COVID-19?
Yes
No
3- Do you currently have ANY of the following symptoms? Fever of 38C / 100.4F or higher?
Yes
No
New Onset or worsening of chronic Cough?
Yes
No
Shortness of Breath?
Yes
No
Sore Throat?
Yes
No
Runny Nose?
Yes
No
Flu Like Symptoms (Fatigue, Joint Pain, Muscle Ache)?
Yes
No
4- Does anyone living in your household have ANY of the above symptoms?
Yes
No
5- Have you or anyone in your house tested positive for COVID-19?
Yes
No
If you answer “YES” to any of above question, we ask that you immediately contact the clinic at 905-237-7174 to discuss appropriate next steps and in-person appointments alternatives.
Declaration:
I have answered all the above questions honestly and truthfully
Signature
Skip to content
Open toolbar
Accessibility Tools
Accessibility Tools
Increase Text
Increase Text
Decrease Text
Decrease Text
Grayscale
Grayscale
High Contrast
High Contrast
Negative Contrast
Negative Contrast
Light Background
Light Background
Links Underline
Links Underline
Readable Font
Readable Font
Reset
Reset