Online Consent Form

1. Do you have any concerns regarding a COVID-19 infection? 1. Do you have any concerns regarding a COVID-19 infection? Yes No

2. Did you have close contact with anyone with acute respiratory illness or travelled outside of Ontario in the past 14 days? 2. Did you have close contact with anyone with acute respiratory illness or travelled outside of Ontario in the past 14 days? Yes No

3. Are you awaiting COVID-19 testing results, have been asked to self-isolate, or have close contact with someone that has symptoms or who is awaiting COVID-19 testing results? 3. Are you awaiting COVID-19 testing results, have been asked to self-isolate, or have close contact with someone that has symptoms or who is awaiting COVID-19 testing results? Yes No

4. In the past 14 days have you had any of the following symptoms: 4. In the past 14 days have you had any of the following symptoms: Fever New onset cough Worsening chronic cough Shortness of breath Difficulty breathing Sore throat Difficulty swallowing Decrease or loss of sense of taste or smell Chills Headaches Unexplained fatigue/malaise/muscle aches (myalgia) Nausea/vomiting, diarrhea, abdominal pain Pink eye (Conjunctivitis) Runny nose/nasal congestion without other known cause None of the above

5. Are you 70 years of age or older, are they experiencing any of the following symptoms: 5. Are you 70 years of age or older, are they experiencing any of the following symptoms: Delirium Unexplained or increased number of falls Acute functional decline Worsening of chronic conditions None of the above

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

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. 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. Yes No

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

9. I Understand all of the above specific COVID-19 precautions and considerations, I consent to proceed with treatment at The Ancaster Foot Clinic. 9. I Understand all of the above specific COVID-19 precautions and considerations, I consent to proceed with treatment at The Ancaster Foot Clinic. Yes No

10. I have read, understood and consent to the all the information points presented in the previous (patient guidance) page. 10. I have read, understood and consent to the all the information points presented in the previous (patient guidance) page. Yes No

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