MANDATORY COVID-19 SELF-ASSESSMENT and INFORMED CONSENT
Dr. Else H. Larsen
104 - 3077 Granville Street
Vancouver, BC, V6H 3J9
UPDATE - On Nov 12/20 we received clarification from the Ministry of Health regarding their new mandate and have updated our mask policy to better reflect their recommendations. We are now requiring all patients, staff, and visitors to our clinic to wear masks with a minimum of three layers. This can be a three layer non-medical mask, or a cloth mask with a filter. We ask that you please bring your own mask to the appointment, and put it on before entering the office. We will be providing masks to patients unable to bring their own.
Please enter your first & last name:
1. Have you recently experienced any of the following?:
New or worsening cough
Shortness of breath or difficulty breathing
Fever or chills
Recent loss or decrease in sense of smell or taste
Runny nose or sneezing (not allergy related)
Nausea/vomiting, diarrhea or abdominal pain
None of the above
2. In the last 14 days, have you traveled outside of BC?
3. Have you provided care or had close contact with a person who:
Has been diagnosed with COVID-19
Has travelled outside of CANADA in the past 14 days
Is sick with a respiratory illness and/or fever
None of the above
4. Have you worked at, or been in contact with someone who lives or works in a hospital or long-term care facility in the last 14 days?
Yes (if yes, go to question 5.)
No (if no, skip question 5.)
5. If you answered Yes to question 4, have you, or the person you have been in contact with, worn the required or recommended PPE according to the type of duties being performed?
6. Have you received any of the COVID-19 vaccines currently approved for use in Canada?
If you answered anything other than "None of the above" or "No" for Questions 1 to 4, please call our office at 604-732-3422 to discuss. For the safety of our patients and staff your appointment may be rescheduled, and it is recommended for you to stay home and self isolate. Pay attention to your health and how you are feeling. You can call 8-1-1 anytime to talk to a nurse at HealthLinkBC and get advice on what to do next.
You agree to inform and notify our clinic in the event that, within a 14-day period following your treatment, you, or someone in your household, experiences any cold or flu like symptoms. This is for the purpose of anonymous contact tracing and to protect the patients and staff at EHL Health.
By signing this form, I am confirming that the above information is correct. I understand that while EHL Health and Dr. Else H. Larsen have taken measures to minimize risk of viral transmission, the nature of my treatment means that physical distancing is not possible during my appointment in the treatment room. Please type your name below:
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