Health Declaration Form – COVID-19Health Declaration Form – COVID-19 *** Required to be completed by every patient prior to commencement of outpatient Physiotherapy treatment at SHAMIM KHAN PHYSIOTHERAPISTPatient Health Declaration Form I, (insert full name below) hereby certify, represent, and warrant as follows: Within the twenty-one (21) days immediately preceding the Date of this Health Declaration Form (“Declaration”): * SECTION A: Please read the following statements and then answer either YES or NO below. If NO provide details in the block below the section: a. I HAVE NOT : tested positive or preemptively positive with the Coronavirus or been identified as a potential carrier of the COVID-19 virus or similar communicable illness (“Coronavirus”) ? * Yes No, I HAVE Select Yes or No b. I HAVE NOT: experienced any symptoms commonly associated with the Coronavirus i.e.: fever (≥38⁰C), cough, sore throat etc. ? * Yes No, I HAVE Select Yes or No c. I HAVE NOT been in any location positively designated as hazardous and/or potentially infected with the Coronavirus by a recognized health or regulatory authority, such as countries deemed high risk for Coronavirus as per the President’s declaration in terms of the National Disaster ? * Yes No, I HAVE Select Yes or No d.I HAVE NOT: been in direct contact with or the immediate vicinity of any person I knew and/or now know to be carrying the Coronavirus or has been identified as a potential carrier of the Coronavirus? * Yes No, I HAVE Select Yes or No If you answered NO to any of the questions in SECTION A please give details in the block below: SECTION B. Read the following statements and select YES OR NO from the drop-down box. If you answered NO provide reasons in the text area below this section.. I CAN account for all locations visited over the previous twenty-one (21) days and shall provide an exhaustive list of all locations visited and modes of transportation used on request. * * Yes No SELECT YES OR NO I AGREE to notify the Physiotherapist of any change in status, including diagnosis with Coronavirus and/or quarantine, within thirty (30) days either before or following this appointment. * * Yes No SELECT YES OR NO I WILL, if asked, wear a mask at all times while receiving treatment and will take all reasonable prophylactic steps that may be recommended by the Physiotherapist. * * Yes No SELECT YES OR NO I WILL consent to having my temperature taken by any representative of the practice prior, during, and/or after any treatment, and will provide any follow up information reasonably requested by the Physiotherapist * * Yes No SELECT YES OR NO If you answered NO to any of the statements in SECTION B, please provide your reasons in the block below: Due to the nature of the CORONA virus I ACKNOWLEDGE and ACCEPT the potential risk of exposure to the virus during my visit at this facility, even with all possible risk has been mitigated by the practice and all precautions as described by law has been put in place. * * select from the drop down box Agree Disagree Select Agree or Disagree to the above condition I ACKNOWLEDGE and ACCEPT that this Declaration shall be governed by the laws of South Africa. I irrevocably agree that the Courts of South Africa shall have jurisdiction to hear and determine any suit, action or proceeding, and to settle any dispute which may arise out of, under, or in connection with this Declaration and for such purposes hereby irrevocably submit to the jurisdiction of such Courts. Nothing contained herein shall limit the right of SHAMIM KHAN PHYSIOTHERAPIST to take proceedings in any Court. * * select from the drop down box Agree Disagree Select Agree or Disagree to the above condition I ACKNOWLEDGE and ACCEPT that this Declaration will be considered as my consent to SHAMIM KHAN PHYSIOTHERAPIST to disclose, share, record and store this Declaration with any relevant authority or service provider for the purposes of ensuring the safety and security of any and all third parties that may come in contact with me prior, during, and after this treatment. * * select from the drop down box Agree Disagree Select Agree or Disagree to the above condition If over the previous twenty one (21) days prior to the treatment, I have visited any of the countries deemed as high risk for the Coronavirus as per the President’s declaration in terms of the National Disaster, I AGREE to provide a written verification executed by a certified physician or a medical facility prior to treatment that (i) a CDC-approved Corona virus test was administered on me and was negative or (ii) I do not meet the CDC criteria for administering a Coronavirus test and do not exhibit any Coronavirus symptoms. * * select from the drop down box Agree Disagree Select Agree or Disagree to the above condition I AFFIRM that all the above statements apply equally to the following person and/or minor under the age of 12 accompanying me (either with me or with my consent) to this appointment: * * select from the drop down box Agree Disagree Select Agree or Disagree to the above condition If any above statement is not wholly true, please provide a full explanation here * In signing below (Printing Your Name), I, an individual over the age of 12 of sound mind, knowingly, voluntarily, and freely agree to the terms of this binding Declaration, and in doing so represent the truthfulness and veracity of the above answers. * Printing Your Name Your ID Number * Phone Your Contact Number Email * Date * Submit