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COVID19 SCREENING FORM

I acknowledge the contagious nature of the Coronavirus/COVID-19 and that the Ontario health authorities recommend practicing teletherapy except in the cases that a client would clinically benefit more from in-person sessions. 

I acknowledge that The Insight Clinic has put in place preventative measures to reduce the spread of the Coronavirus/COVID-19 such as sanitation of touched areas between clients, and increased time between clients for cleaning and to prevent overlap in the hallway. 

I further acknowledge that The Insight Clinic can not guarantee that I will not become infected with the Coronavirus/COVID-19. 

I understand that the risk of becoming exposed to and/or infected by the Coronavirus/COVID-19 may result from the actions, omissions, or negligence of myself and others. 

I voluntarily seek services provided by The Insight Clinic and acknowledge the increased risk of possible exposure to the Coronavirus/COVID-19. 

I acknowledge that I must comply with all set procedures to reduce the spread while attending my appointment.

BY FILLING THE INFORMATION BELOW, I ATTEST THAT:

  • I am not experiencing any symptoms of illness such as cough, shortness of breath or difficulty breathing, fever, chills, repeated shaking with chills, muscle pain, headache, sore throat, or new loss of taste or smell. 
  • I have not travelled internationally within the last 14 days. 
  • I have not travelled to a highly impacted area within the last 14 days. 
  • I do not believe I have been exposed to someone with a suspected and/or confirmed case of the Coronavirus/COVID-19. 
  • I have not been diagnosed with Coronavirus/COVID-19 and not yet cleared as non-contagious by provincial or local public health authorities. 
  • I am following all Ontario Authority’s (and the city of Whitby) recommended guidelines as much as possible and limiting my exposure to the Coronavirus/COVID-19. 

Covid19 Screening
First Name *
Last Name *
Therapist *
Phone *
Client ID
Notes
I agree to the Liability Waiver and Electronic Signature.

Liability Waiver
I understand that this release discharges The Insight Clinic from any liability or future claim that I, or my family, may have against the office with respect to the contraction of Coronavirus/COVID-19.

Electronic Signature
I agree that should I choose to sign electronically; my electronic signature is the legally binding equivalent to my handwritten signature. My electronic signature has the same validity and meaning as my handwritten signature. I will not, at any time in the future, repudiate the meaning of my electronic signature or claim that my electronic signature is not legally binding.

To sign please check the box above.

Get In Touch

302-101 Mary St. West
Whitby, ON
9:00 AM – 5:00 PM
289-483-0133

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