Client Health Screening Form

Please fill out this mandatory screening form within 2 hours of your appointment so we have your most up-to-date health status. We know it's annoying, but it needs to be done to protect yourself and others in the clinic. Please ensure you have completed the BC COVID-19 Symptom Self-Assessment Tool before continuing.

CLICK HERE 👇

BC COVID-19 SELF-ASSESSMENT TOOL

**Then return to this screen to complete the form**

The result of my BC COVID-19 Symptom Self-Assessment Tool is... *

Acknowledgements *

I knowingly and willingly consent to having physiotherapy assessment/treatment completed in-person at Dockside Physiotherapy during the COVID-19 pandemic and the inherent risks it carries of being in close proximity with my therapist. I understand the clinic team at Dockside Physiotherapy is abiding by provincial and regulatory college guidelines to help keep me safe to the best of their ability while at the clinic. I understand that if I answered anything other than "You don’t appear to have symptoms of COVID-19" on the BC COVID-19 Symptom Self-Assessment Tool, that I WILL NOT enter the clinic and will contact Dockside Physiotherapy to cancel and reschedule my appointment(s). I understand that Dockside Physiotherapy may also cancel and reschedule my appointment(s) if I was subject to a known exposure event or if I refuse to follow any of their Clinic Safety Protocols (such as mask wearing and proper hand hygiene). I understand that providing inaccurate information can have serious medical consequences for other clients in the clinic, those in my community, and the clinic team at Dockside Physiotherapy. By entering my name and signing below, I certify the above statements to be true and correct to the best of my knowledge, and that my digital signature is valid and as legally binding as my physical signature once I press "Submit".

DATE *

Date

NAME *

First Name Last Name

SIGNATURE HERE 👇 (...then click "Submit") *

Clear