Covid Consent Ontario Cardio Imaging COVID PATIENT SCREENING Patient Name Please confirm EACH of the following before entering I have NOT received public health or medical advice to self-monitor or self-isolate for COVID I do NOT have a fever and/or new onset of cough or difficulty breathing I have NOT returned from travel outside of Canada in the 14 days before the onset of illness I have NOT had close contact with a confirmed or probable case of COVID (novel coronavirus) I do have NOT close contact with a person with acute respiratory illness who returned from travel outside of Canada within 14 days prior to their illness onset I do not have COVID test results pending Do NOT enter the clinic if you are unable to confirm all of the above. Please note that failure to answer the above truthfully may result in spread of COVID. The clinic will be obliged to report this to provincial authorities. Signature Please, put your signature Send
