COVID-19 Consent Form

Chronic Pain, Orthopaedics & Sports Injuries, Acupuncture,

Massage Therapy, ICBC and WorkSafeBC Claims

#102-22561 Dewdney Trunk Road Maple Ridge, BC V2X 3K1

Phone: (604) 467-8775 . Fax: (604) 467-8704

www.mapleridgephysio.com

COVID-19 Consent Form

I understand that the novel coronavirus, COVID-19, has been declared a worldwide pandemic by the

World Health Organization. I further understand that COVID-19 is very contagious with long incubation

period during which carriers of the virus may not show symptoms and still be contagious. It is believed

to spread by person-to-person contact; and, as a result, public health authorities recommend social

distancing.

I recognize that the staff at Maple Ridge Physiotherapy and Pain Clinic are closely monitoring this

situation and have put in place reasonable preventative measures aimed to reduce the spread of COVID-

19.

However, given the nature of the virus, I understand there is an inherent risk of becoming infected with

COVID-19 simply by being in the clinic.

I understand that public health authorities recommend individuals to maintain physical distancing of at

least 2 metres (6 feet) and it is not possible to maintain this distance and receive treatment.

I hereby acknowledge and assume the risk of becoming infected with COVID-19 by attending in-person

appointments.

I understand that TeleRehab is an option that would eliminate such risk. Deferring in-person treatment

is also an option I have considered.

I understand the potential risk of COVID-19 exposure, and I would like to proceed with my desired

treatment.

I knowingly and willingly consent to physiotherapy/massage therapy/kinesiology treatment during the

COVID-19 pandemic.

_____________________________________ _____________________

Patient Name Date (YYYY/MMM/DD)

I agree that checking this box constitutes an electronic representation of my signature.