Consent - Richmond Clinic - COVID Medical

Consent – Richmond Clinic

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

Richmond Clinic
Name(Required)
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.
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.
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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.