Thank you for your support!

Before your appointment, please fill out the following questionnaire. This helps us ensure the safety of all our clients.

  • Barbara Schultze
  • RMT, D.O.M.P., D.Sc.O.
  • Osteopathic Manual Practitioner

COVID-19 Pandemic Treatment Consent Form

I understand the novel coronavirus causes the disease known as COVID-19. I understand that COVID-19 has a long incubation period during which carriers of the virus may not show symptoms and still be contagious. I understand that despite best efforts on the part of Barbara Schultze at the Elan Clinic, due to the frequency of visits of other patients, the characteristics of the COVID-19, and procedures/therapies offered, that I or my child may have an elevated risk of contracting COVID-19 simply by being at the clinic. I have been advised that my therapist will be using the COVID-19 Symptom Self-Assessment and will be taking their temperatures daily. I have been advised that all clinicians and staff at this clinic are following the guidelines as outlined by the Government of Saskatchewan, the Government of Canada, Saskatchewan Public Health, and the Ontario Association of Osteopathic Manual Practitioners. These include guidelines for:

  • Cleaning and sanitization with products approved by Health Canada.
  • The use of Personal Protective Equipment (PPE) (mask, face shields, gloves and clinic clothing changed after each client).
  • Procedures to maintain social distancing and staggering of appointment times (Only one patient allowed in the clinic at one time unless the client is being accompanied by one caregiver).
  • Minimizing items that are deemed nonessential.
  • Contactless payments by means of credit card or e-transfer payments only.

I confirm I (and my child) have taken the pre-screen COVID-19 Self-Assessment Test.

If you have not taken the COVID-19 Self-Assessment Test, we ask that you not attend at the clinic.

I confirm I will (as well as my child, if relevant) sanitize/wash hands prior to entering the clinic room.

I confirm, I am NOT waiting for the results of a laboratory test for the novel coronavirus.

I verify that I have NOT returned to Saskatchewan from any country outside of Canada whether by car, air, bus or train in the past 14 days.

I understand that any travel from any country outside of Canada, including travel by car, air, bus or train significantly increases my risk of contracting and transmitting the novel coronavirus. The Government of Canada and Saskatchewan Public Health require self-isolation for 14 days from the date a person has returned to Canada.

I understand that The Government of Canada and Saskatchewan Public Health have asked patients to maintain a distance of at least 2 metres, except when receiving services or for brief exchanges.

I verify that I have NOT been identified as a contact of someone who has tested positive for novel coronavirus or been asked to self-isolate by Saskatchewan Public Health.

At of the time of my appointment I do not have any of the following symptoms:

Severe difficulty breathing

Severe chest pain

Confusion or feeling unsure of where you are

Recent loss of consciousness

Have you or anyone in your household returned from travel outside of Saskatchewan in the last 14 days?

Have you or anyone in our household returned from travel outside of Canada in the last 14 days?

Have you had any of the following symptoms in the last 14 days?

I verify the information I have provided on this form is truthful and accurate.

I knowingly and willingly consent to receive treatment during the COVID-19 pandemic.

Élan Osteopathic Clinic is privileged to provide trusted Osteopathic services to the people of Regina, White City, Balgonie, Edenwold, Pense, Pilot Butte, Grand Coullee, Lumsden, Craven, Southern Saskatchewan and beyond.