COVID-19 Screening

The following mandatory screening form needs to be completed prior to your upcoming appointment. It is part of my commitment to your safety, and it will need to be reaffirmed prior to every session until such time as enhanced infection control protocols are deemed no longer necessary by the College of Massage Therapists of Ontario and the Ministry of Health. Thank you for your understanding and co-operation.

Name

Date

1. Have you received your final (or second) vaccination dose more than 14 days ago?

Yes No

*a fully immunized individual is defined as any individual who has received their second dose of any two dose COVID-19 vaccine series or their first dose of one-dose COVID-19 vaccine series more than 14 days ago.

If you’ve answered YES to question 1, answer questions 2 and 3
If you’ve answered NO to question 1, answer questions 2, 3, 4 and 5

2. Do you currently have any of the following symptoms (check any that apply):

Fever and/or chills New onset of cough or worsening of chronic cough Shortness of breath Decrease or loss of sense of taste or smell

If adult > 18 years of age:

Unexplained fatigue/lethargy/malaise/muscle aches (myalgia)

Yes No

If child < 18 years of age:

Nausea/vomiting, diarrhea

Yes No

3. Have you tested positive for COVID-19 in the past 10 days or have you been told you should be isolating?

Yes No

4. Have you travelled outside of Canada in the past 14 days?

(to be answered only if patient not fully immunized)

Yes No

5.Have you had close contact with a confirmed case of COVID-19 without wearing appropriate PPE?

(to be answered only if patient not fully immunized)

Yes No

COVID-19 Self-Assessment

If you feel like you are experiencing symptoms associated with COVID-19 we encourage you to self-isolate and complete the online self-assessment tool before calling your doctor or Telehealth Ontario.

Start Self-Assessment

Telehealth 1-866-797-0000

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info@vctherapeutics.ca
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Our Team
Services & Fees
Patient Information
COVID-19 Info
Book
Contact

RMT Update

At the current time, we are not accepting any new massage therapy patients.

If you have been referred to our massage therapist, please call (519-208-2352) or email (info@vctherapeutics.ca) the clinic to discuss booking as any online booking for a new patient may not be accepted.

Thank you and have a healthy day!

COVID-19 Screening

If you’ve answered YES to question 1, answer questions 2 and 3If you’ve answered NO to question 1, answer questions 2, 3, 4 and 5

If adult > 18 years of age:

If child < 18 years of age:

(to be answered only if patient not fully immunized)

(to be answered only if patient not fully immunized)

COVID-19 Self-Assessment

RMT Update

If you’ve answered YES to question 1, answer questions 2 and 3
If you’ve answered NO to question 1, answer questions 2, 3, 4 and 5