COVID-19 Patient Consent Form

Date *

Day

Month

Year

First Name *

Please enter your first name here.

Last Name *

Please enter your last name here.

Email Address *

Please enter your email address.

Phone Number *

Please enter your phone number.

Cold / Flu / Covid Symptoms *

Have you or anyone in your household experienced any cold/flu or Covid symptoms in the last two weeks?

Yes

Tested positive for COVID-19 *

Have you been exposed to anyone who has tested positive for COVID-19 in the last two weeks?

Yes

If you have answered yes to either of these questions, please call the clinic directly at (250) 477-0240 as your appointment will need to be postponed.

Leave this field blank

Search form