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This form is to be used by people who will be visiting an Anova or Juno location. It should be completed immediately before your appointment.
Please complete all fields.
This declaration form is a requirement by Public Health Ontario to limit the risk of COVID-19 exposure while providing care. If you have any questions or concerns, please contact us at firstname.lastname@example.org
Location and time of appointment
If "Yes" please complete the following fields
I attest that the above statements are true and valid to the best of my knowledge.
We have now reopened and are booking appointments with new COVID-19 protocols in place:
Please call us for more information or to book an appointment