COVID-19 Self-Declaration-Form

The self-declaration form is required in order to screen and safeguard the health and safety of Appleby Foot Care & Orthotics employees and patients.

hereby certify, represent and warrant as follows: Within the last twenty-one (21) days, I HAVE NOT:

tested positive or presumptively positive with the COVID-19 or been identified as a potential carrier of the COVID-19 virus or similar communicable illness ("Coronavirus")
experienced any symptoms commonly associated with the Coronavirus that includes.

severe difficulty breathing
severe chest pain
recent Los of consciousness
fever
new cough
sore throat
new severe headaches, diarrhea, stomach ache
muscle aches
Fatigue

been in any location positively designated as hazardous and/or potentially infected with the COVID-19 by a recognized health or regulatory authority, such as a country for which the Government issued a Travel Advisory for COVID-19
been in direct contact with or the immediate vicinity of any person I knew and/or now know to be carrying the COVID-19 or has been identified as a potential carrier of the COVID-19.

Do any of the following apply to you?

Above the age of 65
Conditions affecting the immune system such as auto-immune disease, HIV etc.
A chronic health condition such as diabetes, COPD etc.
Any treatment affecting immune system such as corticosteroids, chemotherapy etc

I AGREE to notify Appleby Foot Care & Orthotics of any change in status, including diagnosis of COVID-19

I WILL, wear a mask at all times while in Appleby Foot Care Orthotics, and will take all reasonable protective steps that may be recommended by Appleby Foot Care & Orthotics, Chiropodist, and/or staff.

I WILL consent to having my temperature taken, if required by a Chiropodist before, during and/or after any procedure performed at Appleby Foot Care & Orthotics.

I ACKNOWLEDGE and ACCEPT that this Declaration will be considered as my consent to Appleby Foot Care & Orthotics, to disclose, share, record and store this Declaration with any relevant authority or service provider for the purposes of ensuring the safety and security of any and all third parties that may come in contact with me prior, during and after any procedure.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Patient Name:

Date:

Thank you for this information and helping us prevent the spread.

Your information will be encrypted.