Online Consent Form

Please read and sign the consent form below before visiting the Ancaster Foot Clinic in Ancaster.

Upper James Foot Clinic Staff
Please bear with us as we follow COVID-19 health and safety protocol prior to your highly anticipated upcoming visit. Please, thoughtfully consider the content below and electronically sign your understanding and consent, by filling out the form below prior to your appointment.

COVID-19 PATIENT GUIDANCE

1. In addition to the conventional considerations, special caution applies to those with underlying health conditions that may compromise their immunity such as active cancer treatment, uncontrolled diabetes or compromised lung, heart, liver, or kidney function. Being 65  is also considered a risk factor in this circumstance.
2. We are delighted to greet and treat you at The Ancaster Foot Clinic! Please consider that although the COVID-19 curve is flattening, the virus is still active in our community, hence we all, unfortunately, are at risk.
3. Be assured that The Ancaster Foot Clinic has taken every precaution for the health and safety of you, community and our staff.  Be assured, The Ancaster Foot Clinic team will be in full PPE and following Health and Safety Protocol.
4. Patient scheduling is buffered with time to disinfect rooms, spaces, equipment and physically distance interactions.
5. You will be asked to wait in your vehicle until you are notified via text/phone when you may be safely escorted to your treatment room.
6. It is recommended to leave additional coats and belongings in your vehicle.
7. During this cautionary time, only essential guests are allowed to escort you.
8. If possible, please, bring your own mask as per your comfort level.
9. Please know that your temperature will be taken and recorded upon arrival at our clinic. A contactless thermometer will be used.
10. The waiting room, communal magazines and educational paper material are no longer available.
 11. It is recommended to use the washroom facilities before leaving your home to minimize the possibility of spreading the virus.
CONSENT TO EXAMINATION and TREATMENT PROCEDURES

1. Do you have any concerns regarding a COVID-19 infection?

2. Did you have close contact with anyone with acute respiratory illness or travelled outside of Ontario in the past 14 days?

3. I confirm that I am not awaiting COVID-19 testing results, I have not been asked to self isolate, nor do I have close contact with someone with symptoms or who is awaiting COVID-19 testing results.

4. In the past 14 days have you had any of the following symptoms:

5. Are you 70 years of age or older, are they experiencing any of the following symptoms:

6. If you have answered YES to any of these questions please DO NOT attend your appointment. Contact the office at 905-648-9176.

7. I understand that The Ancaster Foot Clinic treatment will require that I breach the recommended 2 metre (6 feet) physical distancing. Potentially, this could expose me to unforeseen COVID-19 exposure.

8. Be assured that The Ancaster Foot Clinic team will be in full PPE and following Health and Safety Protocol.

9. I Understand all of the above specific COVID-19 precautions and considerations, I consent to proceed with treatment at The Ancaster Foot Clinic.

10. I have read, understood and consent to the all the information points presented in the previous (patient guidance) page.

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