COVID19 Health Screening Questionnaire
Do you have a fever? (Fever is a temperature of 38 degrees Celsius or greater)
Are you experiencing a new onset of cough, worsening chronic cough, shortness of breath, or difficulty breathing?
Do you have 2 or more of the following signs or flue like symptoms (without any other known cause)?
Have you traveled outside of British Columbia in the past 14 days?
Have you been diagnosed as a confirmed or probable case of COVID-19 and/or directed to self-isolate in the past 14 days?
Did you provide care or have close contact with a person with confirmed COVID-19? Note: This means you would have been contacted by your health authority’s public health team.

Consent and Release of Liability, Waiver of all Possible Claims and Assumption of Risk

**Please review before signing**

I hereby acknowledge that I have agreed to meet with Maryla Podgajny, PT (the “HCP”) at On The Coast Physio, 5700 Cowrie St, Sechelt (the “Facility”) for the purpose of receiving physiotherapy assessment and treatment (the “Services”).
I am aware of the Clinic's enhanced policies and procedures in regards to COVID-19.

Acknowledgment of Risks

Despite the measures that have been implemented to date, there is still a general, inherent risk of individuals contracting COVID-19. 

I acknowledge and accept that there is a risk that I could be exposed to COVID-19 while attending at the Facility. I also acknowledge and accept that while receiving services, the HCP may need to be closer than the recommended social distancing guidelines (less than 2 meters)  in order to assess and/or treat me. 

I acknowledge and confirm that I am willing to accept this risk as a condition of attending at the Facility to receive services from the HCP.

Consent to Treatment

In consideration of  Maryla Podgajny (PT) HCP, agreeing to see me in person at the Facility, I agree to release Maryla Podgajny at On The Coast Physio and the Facility, their officers, directors, employees, agents and volunteers (the “Releasees”) from any and all causes of action, claims, demands, requests, damages or any recourse whatsoever in respect of any personal injuries or other damages which may occur or arise as a result of exposure to COVID-19 during my visit to On The Coast Physio and/or through the provision of services to me by the HCP.

I do hereby acknowledge and agree that notwithstanding the generality of the foregoing, I declare that I will not commence litigation or otherwise seek to recover damages or other compensation against the Releasees based on any action, claim, demand, request, loss or any recourse whatsoever arising from any potential or actual exposure to COVID-19 while attending at the Facility and/or through the provision of services to me by the HCP. I further acknowledge that the Releasees can rely on this Release of Liability, Waiver of all Possible Claims and Assumption of Risk as a complete defence to any and all claims, damages, causes of action, or recourse or liability that may arise at any time.

Informed consent:
In addition, you agree that you will not attend the clinic for the appointment if at any time prior to arrival you experience any symptoms related to illness from COVID-19. If you are experiencing any symptoms related to illness from COVID-19, you agree to cancel your appointment and cancellation charges shall be waived.

COVID-19 Contact Tracing

In case a COVID-19 exposure occurs in the clinic, the Public Health Authority will need access to personal information for all persons who have entered the clinic. You agree to have your personal information shared with the Public Health Authority upon request for contact tracing purposes only.

I consent to the sharing of my personal information as requested by the Public Health Authority for contact tracing purposes. 
I have carefully reviewed this Release of Liability, Waiver of all Possible Claims and Assumption of Risk and acknowledge that I fully understand the terms as set out above. I acknowledge that I am signing this Release of Liability, Waiver of all Possible Claims and Assumption of Risk voluntarily.

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