COVID-19 Patient Form Full Name (Required) I hereby declare that I or anyone in my household has not experienced any cold or flu-like symptoms in the last 14 days (to include fever, cough, sore throat, respiratory illness, difficulty breathing). If I or anyone in my household experienced any cold or flu-like symptoms after submitting this form, I will not visit the clinic for a minimal period of 14 days after the cold or flu-like symptoms have completely gone away. I agreeI do not agree I hereby declare that I or any member of my household have not traveled to or had lay-over in any country outside Newfoundland in the past 14 days. If I or anyone in my household travel to any country outside of Newfoundland after submitting this forms, I will not visit the clinic for a minimal period of 14 days after the date of return to Newfoundland. I agreeI do not agree I hereby declare that if there is any change to the above status at the time of my visit to TSL Physio that I will call the clinic to advise them and cancel my appointment. I agreeI do not agree This form must be completed PRIOR to your first visit back with TSL Physio. If you have already completed this form post clinic re-opening, you are not required to fill out again at this time. You only need to complete this form once for any services with TSL Physio scheduled from June 8th 2020 onward.