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

Select your treatment option.

I am a Returning Prevention Patient and currently have COVID-19 symptoms for 5 days or less: RETURNING PREVENTION PATIENT:EARLY TREATMENT REVIEW WITH HEALTH CARE PROFESSIONAL ($129.00)

This appointment type is for Returning Prevention Patients (that have COVID-19 "On the Shelf" Readiness Treatment Protocol at home) that would like connect with a Health Care Practitioner to ensure that the patient is understanding the protocol and is taken the protocol properly.

Confirmation of Appointment Requested

I am an adult (18 years and older) and am applying for the COVID-19 Early Treatment Review with a Health Care Professional (15min) appointment for $129.00

This confirmation is required to ensure that you understand what service you are requesting.

I understand that I am responsible for the additional cost of the prescribed medications and nutraceuticals.

I understand that the treatment type and fee that I am signing up for may change after a review of my intake form by a health care practitioner to ensure appropriate treatment is adjusted to reflect my current health conditions and risks, and upon agreement between me and CC TeleHealth.

What was your Primary Health Care Practitioner's response to your request?

Please let us know why you have not requested this service from your Primary Health Care Practitioner.

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

Patient Information

First Name

Last Name

Date of Birth

Addresss Line 1

Apartment Number

Address Line 2

City

Postal Code

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 registration@ccth.ca or call us at (647) 722-5292.

Email Address

Phone Number (Primary)

Phone Number (Alternate)

What is your job title?

Primary Caregiver - Contact Information

Primary Caregiver's First Name

Primary Caregiver's Last Name

Primary Caregiver's Relationship to Patient

Primary Caregiver's Address Line 1

Apartment Number

Address Line 2

City

Postal Code

Primary Caregiver's Email Address

Primary Caregiver's Phone Number (Primary)

Primary Caregiver's Phone Number (Alternate)

Physical Health Background

Height

Age

Weight

Do any of the following apply to you?

I smoke.

I use recreational drugs.

I drink alcohol.

I drink caffeinated beverages.

N/A

Exercise level of intensity that applies to you:

Low Intensity

Moderate Intersity

Vigorous Intensity

Please describe the frequency of your workouts.

Please list all allergies (allergies to medication captured below).

Medical History/Status

Date of Last Family Physician Appointment

Date of Last Physical Appointment

Please list your hospitalizations, diagnosis, surgeries (if applicable) and admission dates.

Please describe any other medical conditions or health issues that we should be aware of.

Please list all medications (including dosages and frequencies) that you are currently taking

Please list all medication allergies.

Please list any vitamins or supplements (including dosages and frequency) that you are currently taking.

I am currently:

Pregnant

Breastfeeding

Does not apply

How many weeks pregnant are you?

Menstruation

Normal

Light

Heavy

Regular Frequency

Irregular Frequency

Absent

Menopausal

Does not apply

COVID-19 Vaccine

Date of First Vaccine

Vaccine Batch Number

Please list any adverse symptoms you experienced after your first injection.

Date of Second Vaccine

Vaccine Batch Number

Please list any adverse symptoms you experienced after your second injection.

Date of First Booster

Vaccine Batch Number

Please list the symptoms you experienced after your first booster.

Date of Second Booster

Vaccine Batch Number

Please list the adverse symptoms you experienced after your second booster.

COVID-19 Information

When did your symptoms begin?

Date of Most Recent Positive COVID-19 Test

O2 Saturation %:

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.

Please list all other symptoms you are currently experiencing.

Confirm Information Provided

I confirm that the above information is true and accurate; that I am applying for treatment with full awareness that these treatment practices have been developed through an intense collaboration with treating health care practitioners, and are developed independent of the typical health authority approvals. I understand that the body of knowledge for COVID-19 treatment is limited, and that the treatments provided by CC TeleHealth are based on learned experience of treating organizations, rather than large world-wide studies that take years and the tracking of thousands of patients before mature treatment knowledge is developed

Terms and Conditions - Informed Consent

ACCEPTANCE OF MEMBER RESPONSIBILITIES & COMMITMENTS

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).

ACCEPTANCE / DELIVERY OF INFORMED CONSENT FOR TREATMENT OF COVID-19

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 https://www.healthlinkbc.ca/medications/fdb5119 . 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.

ACCEPTANCE OF THE TERMS AND CONDITIONS OF PROVIDING MY PERSONAL HEALTH INFORMATION TO CC TELEHEALTH

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.

ACCEPTANCE OF SERVICES PROVIDED

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.

I HAVE READ, AND ACCEPT WITHOUT RESERVATION, THE ENTIRE TEXT OF THESE CC TELEHEALTH TERMS AND CONDITIONS INCLUDING MEMBER RESPONSIBILITIES & COMMITMENTS, INFORMED CONSENT FOR TREATMENT OF COVID-19, PERSONAL HEALTH INFORMATION AND ACCEPTANCE OF SERVICES PROVIDED. I AGREE THAT IF I DO NOT ACCEPT THE ENTIRE TEXT OF THESE TERMS AND CONDITIONS, I CANNOT PROCEED FURTHER INTO THE CC TELEHEALTH SYSTEM.

Agreement to Terms and Conditions Date

Typing your name below represents your signature.

Signatory is:

Patient Primary Caregiver

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