Consent - Calgary Clinic

Customer Consent for COVID-19 Screening and Release of Medical Records

Calgary Clinic

Name(Required)

First Middle Last

Address(Required)

By law, we require the above individual’s current residential address in the case that CVM Medical needs to report a positive case to Public Health.

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Email(Required)

Passport #:

Several countries around the world require passport information on the test results in order for the results to be accepted. If this is required please email help@covid-Medical.ca after you receive your test results. We will only make the changes once the test has been confirmed negative.

Consent(Required)

I understand that I am consenting to undertaking Rapid Antigen Screening via bilateral nasal swab collection, to detect the presence of SARS-CoV-2 virus that causes COVID-19 infection. I verify all the information I have provided to be true and correct.

CVM Medical Ltd. is not responsible or liable for any travel expenses, cancellation costs, changes in flight or travel itineraries, inability to work or engage in economic activity, refusal of any authority to accept your screening results, or quarantine by any government or agency

Consent(Required)

I acknowledge that I am consenting to Rapid Antigen Screening via bilateral nasal swab collection and that this test may result in a positive, negative, false positive or invalid result of which CVM Medical is not responsible for reimbursing any costs should the provided result not be of my preference.

Consent(Required)

I also consent to CVM Medical Ltd. collecting and storing my personal information, including my name, address, phone number, email address, date of birth, passport number and personal healthcare number

Consent(Required)

I hereby provide my consent for CVM Medical Ltd. to share my personal information with any government agency, federal or provincial health authority and/or employer when applicable. I understand and consent that CVM Medical Ltd. will notify public health officials (or employer when applicable) in the event my result is positive including my contact information.

Consent(Required)

I agree to conduct the CVM Medical self-assessment screening questionnaire the day of and prior to my appointment. See the Questionnaire below.

Name

This field is for validation purposes and should be left unchanged.

Self-Assessment Questionnaire

COVID-19 Testing

Please read the following screening self-assessment the day of and prior to your appointment. If you answer NO TO ALL of these please proceed with your appointment. Otherwise, please cancel your appointment and contact Public Health immediately. DO NOT show up at clinic. A full refund can be provided by contacting customer service.

1. Are you currently experiencing any of these symptoms (new, worsening, and not related to a medical condition you already have)?

Fever
New onset of cough
Worsening chronic cough
Shortness of breath
Difficulty breathing
Sore throat
Difficulty swallowing
Decrease of loss of sense of taste or smell
Chills
Headaches
Unexplained fatigue/malaise/muscle aches (myalgias)
Nausea/vomiting, diarrhea, abdominal pain
Pink eye (conjunctivitis)
Runny nose or nasal congestion without other known cause

2. Have you tested positive for COVID-19 or had close contact with a confirmed case of COVID-19 without wearing appropriate PPE?

3. Have you travelled outside of Canada in the last 14 days?

This does not include essential workers who cross the Canada-US border regularly.

Vancouver International Airport (YVR)

VANCOUVER, BC

NANAIMO, BC

CALGARY, AB

MOBILE AT HOME TESTING

RAPID COVID-19 TEST

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