Patient Screening
Patient and Staff Screening Tool
Completion of this form is required prior to any member of the public entering the clinic to help us ensure we keep everyone safe and continue our duty to flatten the curve.

* PATIENTS (and CAREGIVERS), please complete this form on the day of your appointment, BEFORE you arrive.

* STAFF, please complete before the start of your shift.

Prior to entering the clinic please ensure you read the "re-open Procedure" to familiarize yourself with our *enhanced* physical distancing and safety procedures.
First Name *
Last Name *
Are you experiencing any of the following symptoms? *
Required
Are you (or anyone with you today) experiencing a new onset of 2 or more of the following symptoms today? *
Required
Within the past 14 days have you (or anyone in your home) travelled outside of Canada? *
Within the past 14 days, have you: **Close contact includes providing care, living with or otherwise having close prolonged contact (within 2 metres) while the person was ill, or contact with infectious bodily fluids (e.g. from a cough or sneeze) while not wearing recommended personal protective equipment.
I agree to wear a mask and sanitize my hands upon entry into Fotis Physio and Wellness for my safety, and the safety of others. *
I agree that the responses I provided are true to the best of my knowledge. I am aware of the risks of entering the clinic and I have been informed of the safety precautions that Fotis Physio and Wellness has in place. I consent to proceeding with in-person care, and having this information collected by the clinic for my safety and the safety of others. *
Thank you for your submitting your responses and helping us control the spread of COVID-19.Rest assured, as we navigate this pandemic, we are doing we are doing so in full alignment with regularly updated recommendations made by credible health authorities like the World Health Organization (WHO), the Canadian Public Health Agency, Provincial Public Health Authorities and the Regulatory Colleges.If you have any questions or concerns please contact a member of the Fotis Physio and Wellness Team.Phone: 705-985-4567
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