Covid Consent Form – Downtown Animal Hospital

Name*

First Last

Date/Time*

AVIMARK #

Mask?*

TEMP: <38°C (100.4°F)*

Are you feeling sick? (Examples include a new cough, headache, weakness, fever, difficulty breathing, etc.)*

Yes
No

If YES then: Return home and contact public health. You may be required to self-isolate.

Have you travelled outside Canada in the past 14 days?*

Yes
No

Did you provide care or have close contact with a person with COVID-19 (probable or confirmed) while they were ill and you did not have appropriate PPE?*

Yes
No

Symptoms of COVID-19 include:

• Fever • Fatigue • Dry cough • Difficulty breathing • Chills • Nausea or vomiting • Diarrhea • Confusion

Consent*

I understand the above symptoms and affirm that I, as well as all household members, do not currently have, nor have experienced the symptoms listed above within the last 14 days.

Consent*

I affirm that I, as well as all household members, have not been diagnosed with COVID19 within the last 30 days.

Consent*

I affirm that I, as well as all household members, have not knowingly been exposed to anyone diagnosed with COVID-19 within the last 30 days.

Consent*

I affirm that I, as well as all household members, have not traveled outside of the country, or to any city outside of our own that is or has been considered a “hot spot” for COVID-19 infections within the last 30 days.

Consent*

I understand that this business and all staff cannot be held liable for any exposure to the virus or any other contagion caused by misinformation on this form or the health history provided by each client.

Consent*

By signing below I agree to each above statement and release the business and all of its employees and contractors from any and all liability for the unintentional exposure or harm due to COVID-19.

Consent*

Your veterinarian and all employees of this facility agree that they abide by these same standards and affirm the same. We also affirm that we have improved and expanded our sanitation protocols to more thoroughly fight the spread of COVID-19 and other communicable conditions.

Signature*

Date*

Precautionary Coronavirus Liability Release Form - Client

Symptoms of COVID-19 include:

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