Face-To-Face Appointment Requirements

If you meet the following self-certification criteria, we may be able help with a face-to-face visit during Alert level 3.

If you answer YES to any questions, please provide further details in spaces provided.

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* 1. Please enter your full name and contact number

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* 2. In the past 14 days you have had contact with a COVID-19 case or, have you visited a current location of interest or do you meet the higher index for suspicion criteria?

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* 3. Have you had any of the following symptoms in the past 14 days?
- Cough                             
- Fever                    
- Nausea
- Sneeze                    
- Sore throat                
- Runny nose
- Shortness of breath           
- Loss of sense of smell or altered sense of taste

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* 4. Will delay in access to services impact your ability to maintain functional independence and significantly negatively impact your quality of life (work,sleep, movement, etc)?

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* 5. Will failure to access chiropractic services lead to an acute deterioration of known condition?

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* 6. Can treatment be delivered by a service which is currently operating or by clinicians that are already in contact with you for ongoing care?

Please print form and sign below to self-certify that the above information is true. If you do not have a printer, we will have you sign below upon entry.

Sign Here: __________________________________________________

Thank you. We will be in contact with you shortly.
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