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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 info@anovafertility.com

Location and time of appointment

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 info@anovafertility.com

Do you have any of the following symptoms?Fever, New onset of cough, Worsening chronic cough, Shortness of breath, Difficulty breathing, Sore throat, Difficulty swallowing, Decrease of loss of sense taste or smell, Chills, Headaches, Unexplained fatigue/malaise, muscle aches (myalgias), Nausea/vomiting, diarrhea, abdominal pain, Runny nose or nasal congestion without , other known cause?
Have you travelled outside of Canada in the past 14 days?

If "Yes" please complete the following fields

Covid Test Result
Have you had close contact with a confirmed case of COVID-19 without wearing appropriate PPE?

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 info@anovafertility.com

I attest that the above statements are true and valid to the best of my knowledge.


Patient Signature
(Sign Here)
Clear Signature

Date

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 info@anovafertility.com

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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 


Covid-19 FAQ's