Name: Mathew Schneider

Date: 2020-07-21

I hereby declare that I or anyone in my household has not experienced any cold
or flu-like symptoms in the last 14 days (to include fever, cough, sore throat,
respiratory illness, difficulty breathing). If I or anyone in my household experience
any cold or flu-like symptoms after submitting this form, I will then not visit the
Clinic for a minimum period of 14 days after the cold or flu-like symptoms have
completely gone away.
Agree

I hereby declare that I or any member of my household have not travelled to or

had a lay-over in any country outside Canada in the past 14 days. If I or anyone in
my household travel to any country outside Canada after submitting this form, I
will then not visit the Clinic for a minimum period of 14 days after the date of
return to Canada.
Agree

I hereby declare that if there is any change to the above status at the time of my
visit to Healthx Physical Therapy I will call the clinic to advise them and cancel my
appointment.
Agree

This form must be completed prior to INITIAL VISIT back to Healthx Physical
Therapy for Physiotherapy, Active Rehabilitation, or Occupational Rehabilitation 1
Program services.
*If you have already filled out the form post clinic re-opening, you are not
required to filled it in again at this time. You only need to fill out this form once
for physiotherapy treatment scheduled from May 19, 2020 onwards.