Online Patient Attestation

Online Patient Attestation

I commit to :   

  • An accurate COVID-19 self assessment prior to coming into the hospital. Please note that honesty is critical and if you are not cleared through screening, please call the clinic and discuss how best to attend your appointment.
  • Practicing physical distancing, using hand sanitizer, putting on a hospital-issued mask and keeping it on the entire time I am in the hospital.
  • If you are refusing not able to wear a mask please contact your clinic in advance of your appointment to discuss.
  • Entering/exiting directly and not wandering.
  • My visitor only being present as per hospital visitor policy.
YES    
My COVID -19 self assessment includes honestly answering the following questions:

1. Are you fully vaccinated against COVID-19?
It has been 14 days or more since your final dose of a two-dose vaccine series. Proof of vaccine & identification is required.   

      
1. Have you tested positive for COVID in the last 10 days and if yes are you still under isolation?
      
2. Do you have any of the following symptoms?
  • fever and/or chills OR
  • cough OR
  • shortness of breath OR
  • decrease or loss of taste or smell OR
  • runny nose/nasal congestion OR
  • headache OR
  • extreme fatigue OR
  • sore throat OR
  • muscle aches/joint pain OR
  • gastrointestinal symptoms (ie. vomiting or diarrhea)
3. In the last 10 days, has someone you live with:
  • been sick with symptoms associated with COVID-19? AND/OR
  • tested positive for COVID-19 (on a rapid antigen test or PCR test)?
4. In the last 10 days, have you tested positive on a rapid antigen test or home-based self-testing kit?  
5. In the last 10 days, have you been identified as a “close contact” of someone who currently has COVID-19 (confirmed by a PCR or rapid antigen test)?