Mount Royal Village Family Chiropractic, Massage & Acupuncture
COVID-19 Screening Tool

Please complete and submit this form on the day of your appointment with Mount Royal Village Family Chiropractic, Acupuncture & Massage.

To ensure the health and safety of both our patients and staff during the COVID-19 pandemic, we require submission of consent in order for patients and staff to attend appointments.

All patients are required to review and submit a consent form prior to coming in for their next appointment.

PLEASE COMPLETE THE PATIENT CONSENT FORM BELOW:

*Required

    *Patient Name:

    Do you have symptoms of COVID-19, such as:

    • Fever ?

    • A new or changed chronic cough?

    • A sore throat that is not related to a known or pre-existing condition?

    • A runny nose that is not related to a known or pre-existing condition?

    • Nasal congestion that is not related to a known or pre-existing condition?

    • Shortness of breath that is not related to a known condition?

    Have you travelled internationally within the last 14 days? -

    Have you had unprotected close contact with individuals who have a confirmed or presumptive diagnosis of COVID-19 (e.g. individuals exposed without appropriate PPE in use).

    *Patients and/or companions exhibiting symptoms can not receive treatment at this time and should call Health Link at 811.

    SIGNATURE OF PATIENT

    I have read and understood the COVID-19 screening criteria

    Date Signed:

    If you have any questions, please contact us at (403) 475-6210 or email us at mountroyalchiropractor@gmail.com.

    Thank you from the team at Mount Royal Village Family Chiropractic,
    Acupuncture & Massage!