Covid-19 Pre-Screening Questionnaire Informed Consent Form

BEFORE YOUR APPOINTMENT
There will be some changes to the way appointments are scheduled and some new procedures for arriving to your appointment to keep you safe.

• Appointments will be spread out so there is no over-lap between patients and that there is adequate time to disinfect between patients. This means there are less appointments available each day. I will try to accomodate the best I can.
• A risk assessment COVID-19 pre-screening questionnaire is available on the website. I MUST get a response from you answering all of the questions PRIOR TO YOUR APPOINTMENT. If I do not, you will be refused treatment upon arrival.
• Ensure you arrive at the time of your scheduled appointment, alone if possible. If you are unable to arrive alone, the person accompanying you will be screened, asked to provide their name and phone number for contact tracing purposes, and to wear a cloth or disposable mask.
• I am asking that you provide your own cloth or reusable mask for each treatrment. If you do not have a mask, you will be refused treatment. PLEASE REMEMBER THIS.

DURING YOUR APPOINTMENT
Although protocol and procedure has changed, you can expect the same standard of treatment and care as before.

• You will be required to wear a mask for the duration of your appointment. I will also be masked for the treatment. If you have a health condition that makes wearing a mask difficult, I will use my professional judgement to assess the risk of continuing treatment.
• You will be asked to sanitize your hands upon arrival as well as after treatment on your way out.
• You will be actively screened and assessed upon arrival.

BEHIND THE SCENES…
Your safety and wellbeing is most important to me. These are difficult and unprecedented times. I am following guidelines set under the Regulated Health Professions Act (RHPA), the Ontario’s Chief Medical Officer of Health (CMOH) and the Ontario Ministry of Health. These are the precautions I am taking;

• Handwashing with soap prior to and after each appointment.
• Disinfecting all hard surfaces with ministry recommended cleaner between each appointment.
• Removing all soft surfaces and unneccesary items from the clinic space.
• Ensuring the remaining items in the clinic space are protected and covered.
• Having a designated work wardrobe, scrubs…for the safety of patients and myself.
• In addition to my extensive education in infectious disease, I have taken the Ontario Ministry of Health’s 10 module course on the proper use of Personal Protective Equipment (PPE).

ADDITIONAL INFORMATION
As you may or may not know, my son, Noah, is immuno-compromised due to the medication he takes for Crohn’s disease and Chronic Kidney Failure. Due to this reason, my bathroom facilities are completely off limits to patients..no exceptions. I apologise for this inconvenience but it is necessary. Please keep this in mind before your appointment and thank you for your understanding.

I want to thank each and every one of you for your patience and understanding during this confusing and unpredictable time. I hope to get back to a normal that allows me to provide treatment regularly and consistently. Please know I am bound to follow the guidelines set out by our Provincial Government and by my Professional Association.

I look forward to seeing you soon.

Karyn (Tizzard) M.OMSc
Osteopathic Practitioner

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