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COVID-19 Pre-screen Form

cOVID-19 PRE-SCREEN form

Please select the type of your request *

New Patient Inquiry
Current Patient Inquiry

Patients will be limited into the office in order to support physical distancing rules.

Name *

First

Last

Phone Number *

Email *

Confirm Email

Message *

Have you traveled internationally in the last 14 days? *

If you answer yes to this question, you are legally required to self-isolate for 14 days from the date of your arrival back into Canada. You are not eligible for chiropractic care at this time. Immediately self-isolate and follow COVID-19 instructions found on the alberta.ca website!

Have you had unprotected close contact with individuals who have an active, confirmed, or presumptive diagnosis of COVID-19 (e.g. individuals exposed without appropriate PPE in use). *

If you answer yes to this question, you are not eligible for chiropractic care at this time. Immediately self-isolate and follow COVID-19 instructions found on the alberta.ca website!

Symptoms of COVID-19: | fever or chills | headache | muscle or joint aches | new or changed chronic cough | sore throat or painful swallowing | runny or stuffy nose | shortness of breath or difficulty breathing | feeling unwell or new fatigue | nausea, vomiting, diarrhea or loss of appetite | loss of sense, smell or taste | conjunctivitis(Pink Eye) | ---< Do you currently have any symptoms of Covid-19? >--- ---< Please check any that apply to you. >--- *

Fever or Chills
Headache
Muscle or Joint Aches
New or changed Chronic Cough
Sore Throat or Painful Swallowing (not related to a known or preexisting condition)
Runny Nose or Stuffy Nose (not related to a known or preexisting condition)
Shortness of Breath or Difficulty Breathing (not related to a known or preexisting condition)
Feeling unwell in general, new fatigue, or severe exhaustion
Nausea, Vomiting, Diarrhea or unexplained Loss of Appetite (Gastrointestinal symptoms)
Loss of Sense of Smell or Taste
Conjunctivitis, commonly known as Pink Eye
I do NOT have any COVID-19 symptoms

If you have any of these symptoms, you are not eligible for chiropractic care at this time. Immediately self-isolate and follow COVID-19 instructions found on the alberta.ca website!

I have provided full disclosure of all information *

I understand, upon my arrival, if I have not disclosed any symptoms or acquired new symptoms since submitting this form, I will be asked to leave and self-isolate. *

I agreed to Terms of Use and Privacy Policies *

I have read and agree to the Terms of Use and Privacy policies for this website. *

Signature of Patient: *

We will contact you to setup an appointment. You will be required to sign this form upon arrival.

**********This section is for Huntington Chiropractic Clinic Use Only!********** *

Date (mm/dd/yyyy):
Signature of Pre-Screener:

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Message

office info

Address

Hunterhorn Plaza
568 - 64 Avenue N.E.
Calgary, Alberta.
T2K 6H9

Email

Send using our Email form

Call 403-275-8567

FAX 403-275-5434

OFFICE HOURS

Monday – Friday 9:00 AM – 12:00 PM
                               2:00 PM – 6:00 PM
Saturday               Closed
Sunday                  Closed
Holidays                Closed

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OUR LOCATION

Huntington Chiropractic in Calgary
We are conveniently located in north central Calgary with easy access to Deerfoot Trail.
Calgary Transit bus routes are located off 4th Street and 64th Avenue N.E.
Free parking available and wheelchair accessible.

CTransit
Parking
Accessible