Physiotherapy Service Provider Information

Name of Clinic: KINESIS PHYSIOTHERAPY AND REHABILITATION CENTRE

Address: 80 THICKSON RD SOUTH, WHITBY, L1N 7T2

I hereby acknowledge that I have agreed to meet with the Physiotherapist at the Facility for the purpose of receiving PHYSIOTHERAPY SERVICES

By agreeing to meet with the Physiotherapist and receive the Services, | am aware of the following:
1. There is a risk that | could be exposed to severe acute respiratory syndrome coronavirus 2, the virus responsible for COVID-19 (hereinafter referred to as “COVID 19”) while attending the Facility to receive the Services. | accept and acknowledge that | could be exposed to COVID 19 through the following means (this list is not exhaustive):

• My physical presence at the Facility;

• My interactions with other patients or members of the public who are present at the Facility at the time o f my attendance;

• My interactions with staff, agents and other health care professionals at the Facility; and

• The physical touching of any equipment or fixtures in the Facility.

2. While receiving services, the Physiotherapist may need to be physically closer to me than the recommended social distancing guidelines in order to assess and/or treat me.
I acknowledge that I have read and fully understand the risks as described above. I| acknowledge and confirm that I am willing to accept these risks as a condition of attending the Facility to receive the Services from the Physiotherapist.
I confirm that any questions that | had regarding the provision of the Services during the COVID 19 pandemic has been answered by the Physiotherapist.