CCTH Form #110 - COVID-19 Prevention Intake Form

CC TeleHealth is NOT a primary healthcare provider, and its services are intended to be complementary to, and not replace, those provided by your general practitioner. Further, CC TeleHealth only provides services that are COVID-19 and Post COVID-19 oriented, that are not covered by provincial health care plans, and charges a fee for its services. You should always first contact your primary health care provider for all "government-insured" health care services.

Warning: If this form is filled out on a cell phone, we may not receive your submission. For the best results, please complete it on a desktop or laptop computer

COVID-19 Prevention Targets

Prescriptions for reducing the likelihood of contracting COVID-19 which are based on your health risks -- if some popular pharmaceuticals are not allowed, there are alternative options that work well;
Coaching on the Guidelines for reducing the risk of contracting COVID-19 and strengthening your immune system, including suggested nutritional supplements;
Treatments (including prescriptions) that should be used as soon as symptoms appear to prevent complications from becoming a reality. Research is conclusive -- the best preventative action to reduce the danger of COVID-19 is early treatment.

If a client becomes infected with COVID-19, EARLY TREATMENT support may also be required, especially if the client is part of a high risk population. Additional treatments (beyond the ones provided to have on hand for immediate treatment when symptoms start) may be needed.

I am an adult (18 years or older) applying for a $179.00 COVID-19 Prevention Appointment.

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

I understand that payment must be made before booking the appointment.

Once payment is received, you will be contacted within 24 hours on weekdays to schedule your appointment.

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

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.

How did you hear about CC TeleHealth?

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)

Please note - you will be contacted by phone or text using your primary phone number

What is your job title?

Date of Last Family Physician Appointment

Date of Last Physical Appointment

Primary Caregiver - Contact Information

Primary Caregiver's First Name

Primary Caregiver's Last Name

Primary Caregiver's Relationship to Client

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)

General Physical Information

Height

Age

Weight

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.

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.

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 Information

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.

Date of Third Booster

Vaccine Batch Number

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

Date of Fourth Booster

Vaccine Batch Number

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

COVID-19 Information

Date of Positive COVID-19 Test

Provide the date of symptom onset if no PCR or Rapid Test completed

Describe the symptoms you experienced when you were sick with COVID-19.

Please indicate the approximate timeframe that you were sick with COVID-19.

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 clients before mature treatment knowledge is developed

Terms and Conditions - Informed Consent

ACCEPTANCE OF CLIENT RESPONSIBILITIES & COMMITMENTS

As the subscribing client, 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. Upon initial registration, I agree to pay the $100 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 $100 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 intake form, referencing their own medical history, and that all forms are properly completed with me as the client 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 adherence to the Cancellation Policy at CC TeleHealth.

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 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 individuals 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 appointment at 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 client will not be refunded. If the health care practitioner cannot make the appointment, the client 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 CLIENT 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:

Client Primary Caregiver

Payment

Please follow the link for payment.

Prevention $179 - Pay Here

I understand that payment must be made prior to booking the appointment. Please select the appropriate link above. You will also find payment links in the confirmation email that you will receive upon submitting this form. (Please monitor your spam or junk folder for an email that provides more information about our process including the payment links.)