CCTH Form #141 - Returning Prevention COVID-19 Treatment Review Intake Form

Please correct the errors described below.

Confirmation of Appointment Requested

CC TeleHealth will call you to ensure the correct credit card is used for payment.

Patient Information

NOTE: We currently do not have a health care practitioner witihn CC TeleHealth in your province to service you. Therefore, please do not continue with completing this form. We apologize for any inconvenience. Should you have any medical issues that require medical attention, please do not hesitate to contact your local medical clinic or nearest hospital.

NOTE: We currently do not have a health care practitioner witihn CC TeleHealth in your province to service you. Therefore, please do not continue with completing this form. Instead, please send an email to or call us at (647) 722-5292.

Primary Caregiver - Contact Information

Physical Health Background


Medical History/Status

COVID-19 Vaccine

COVID-19 Information

NOTE: If your O2 Saturation is below 90%, please call 911 and proceed to the emergency room. CC TeleHealth is unable to provide you service until you have been personally assessed by an emergency physician.

Confirm Information Provided

Terms and Conditions - Informed Consent


As the subscribing member, I accept ALL the following terms, conditions, responsibilities and commitments, for myself, and on behalf of any immediate family member (including elderly parents for whom you have medical power of attorney) for whom I may access these services, including:

1. I agree to pay the $50 lifetime membership fee upon initial registration plus a $50 deposit towards my initial appointment. I agree that this $100 charge is non-refundable, unless a time for the appointment is not made within two weeks of submission. I also understand that the $50 deposit will be deducted from my initial cost of services provided.

2. If I am making appointments for my family, I will ensure that each family member has submitted their own individual patient intake form, referencing their own medical history, and that all forms are properly completed with me as the member listed as the contact person for all family members. I also agree that I will not receive an appointment until complete information, as determined by CC TeleHealth has been provided by me.

3. I agree that I will treat all CC TeleHealth service providers with respect and courtesy at all times.

4. I agree that missing a scheduled appointment will result in cancellation of my membership, and should I wish to again receive services from CC TeleHealth, I will need to again pay the $100 initial payment, subject to same terms and conditions noted above in (1).


In Canada, there are currently no recognized standard outpatient therapies for persons infected by SARS-CoV-2 virus causing COVID-19 disease. The current standard of outpatient care is supportive: i.e., stay home and isolate, drink fluids, take acetaminophen for fever. Should one’s condition progress with worsening symptoms such as difficulty breathing, then they should go to the hospital. There are numerous studies suggesting benefit with the use of certain medications and supplements, but do not have an official indication for COVID-19 disease.

Ivermectin is a medication that was discovered approximately 40 years ago for the treatment of parasites. As of June 16, 2021, there are 59 peer-reviewed clinical studies suggesting that patients who take Ivermectin may have faster improvement and fewer hospitalizations than those not on Ivermectin. Studies have shown that Ivermectin has anti-viral, anti-inflammatory, and immunomodulatory properties. However, use of Ivermectin for COVID-19 has not yet been fully assessed and approved by Health Canada. Taking Ivermectin is not a guarantee of clinical improvement. Some dosing protocols recommend treatment for five days or longer, under physician’s direction, if symptoms persist. Studies suggest results are best when the medication is started as soon as possible. Some of the potential side effects reported in the ivermectin product monograph include dizziness (2.8%), itchiness of skin (2.8%), diarrhea (1.8%) nausea (1.8%) fatigue (0.9%), abdominal pain (0.9%), anorexia (0.9%), constipation (0.9%), vomiting (0.9%), loss of appetite (0.9%), somnolence (0.9%), vertigo (0.9%), tremor (0.9%), rash (0.9%), urticaria (hives) (0.9%). There are no data to indicate there is harm to the fetus for humans using ivermectin during pregnancy based on decades of use. However, you should always weigh the benefits versus risks when using any medication in pregnancy. Additional information on approved uses of ivermectin in Canada and possible side effects, is available at . Because use of ivermectin is “off-label”, meaning Health Canada does not officially recognize the use of this medication for the treatment of COVID-19, signed written consent is required before taking this medication. Your signed consent indicates that you understand you are taking the medication “off-label” for COVID-19, and that beneficial results are not guaranteed.

I agree and accept the above conditions, and hereby provide my informed consent for my own treatment, and on behalf of any other family member for whom I am serving as the contact person, including but not limited to, elderly parents for whom I retain medical power of attorney, and my minor children not yet of legal age in my province.

I also acknowledge and accept that the CC TeleHealth medical professional who provides treatment to me will also confirm my provision of informed consent, and that my failure to reconfirm this provision of informed consent will terminate my membership in CC TeleHealth and no medical services will be provided to me or my family.


I accept responsibility for providing complete personal health information for myself and all family members for whom I am making an appointment / request for medical services. I accept that if I fail to provide complete information on all relevant healthcare history, medications being used, or legal or illegal substances being used, I may cause harm to myself or my family member through use of the CC TeleHealth services. I understand and accept that CC TeleHealth, and its system providers, will keep our healthcare information confidential as is required under the provincial jurisdiction privacy act.

I accept that my/our personal health information will be kept confidential except when: I or a family member say they may hurt themselves or others, we receive a court order, we suspect children are in need of protection or in cases of mandatory disease reporting.


I accept that CC TeleHealth and its service providers will provide their best professional information, advice, treatment, and support to me as they are able. I acknowledge that CC TeleHealth cannot assure me or my family that recommended or prescribed medical treatments will be successful and/or that forms and information provided will be effective and achieve their intended purpose.

I accept that I, and/or my immediate family members for whom I am making appointments are responsible for our own personal medical management. I accept that it is my responsibility, and that of my family members, to make their own requests of and receive primary healthcare services from my/our primary healthcare practitioner(s). I understand and accept that it is my responsibility, and that of my family members, to inform my/our primary care provider(s) of all of my medical information, including services received from CC TeleHealth, but excluding the identity of all CC TeleHealth providers of service to me.

I accept that CC TeleHealth is an outpatient service only, and that if I or any member of my family has an oxygen saturation level less than 90% and/or new shortness of breath or difficulty breathing, and/or new chest pains and/or dehydration, it is my responsibility to immediately abandon this registration and call 9-1-1, the public emergency number and obtain the urgent medical services that I or my family member needs immediately. I further acknowledge and accept that CC TeleHealth can only provide outpatient health services, and that some people have complex medical conditions that are beyond the scope of services available through a telehealth service, and therefore CC TeleHealth reserves the right to decline to provide telehealth services in such circumstances and refer them to their primary care practitioner or the emergency department of the local hospital.

I accept that once an appointment is established, “no shows” by the patient will not be refunded. If the health care practitioner cannot make the appointment, the patient has the option to be fully refunded or rescheduled.

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