Did you have close contact with anyone with acute respiratory illness or travelled outside of Ontario in the past 14 days? *

Yes

No

Do you have a confirmed case of COVID-19 or have you had close contact with a confirmed case of COVID-19? *

Yes

No

Do you have any of the following symptoms:

Fever
New onset of cough
Worsening of chronic cough
Shortness of breath
Difficulty breathing
Sore throat
Difficulty swallowing
Decrease or loss of sense of taste or smell
Chills
Headaches
Unexplained fatigue/malaise/muscle aches (myalgias)
Nausea/vomiting, diarrhea, abdominal pain
Pink eye (conjunctivitis)
Runny nose/nasal congestion without other known cause

*

Yes

No

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

Yes

No

Not Applicable

I attest that I have read the above statements and that prior to coming into Therapy Spot on today's date that neither my child nor I have any of the above symptoms.

Patient First Name: *

Patient Last Name: *

Parent/Guardian First Name: *

Last Name: *

Relationship To Patient: *

Date

Informed Consent

Speech Language Pathology Treatment at Therapy Spot in the Era of COVID-19

Thank you for your continued trust in our practice. As with the transmission of any communicable disease like a cold or the flu, you may be exposed to COVID-19, also known as “Coronavirus”, at any time or in any place.

Please be assured that at Therapy Spot, we have always followed regulations and recommended universal personal protection and disinfection protocols to limit transmission of all diseases in our office and continue to do so.

Despite our careful attention to sterilization, disinfection, and use of personal barriers, there is still a chance that you could be exposed to an illness in our office, just as you might be at your gym, grocery store, or favourite restaurant. “Social Distancing” nationwide has reduced the transmission of the Coronavirus. Although we have taken measures to provide social distancing in our practice, due to the nature of the services we provide, it is not possible to maintain social distancing between patient and therapist, Therapy Spot staff and sometimes other patients at all times.

Although exposure is unlikely, do you accept the risk and consent to treatment? *

Yes

No