Consent Form During Covid-19 Pandemic

All patients (new and existing) should sign the Pandemic Consent until further notice.

I here declare that:



I have checked the website of Southcentre Chinese Acupuncture and am aware the safety
measures implemented in the clinic. I understand that despite all the protocols there are still
risks associated with contraction of Covid-19 during my visit to the clinic.

I allow the disclosure of contact information in the event that a patient who has visited the clinic in the last 14 days and is now testing (or has tested) positive for Covid-19.




All information contained herein is protected by privacy laws including the Personal Information Protection and Electronic Documents Act (PIPEDA) and all the corresponding provincial legislation. All users agree to protect the personal health information contained herein from unauthorized use, disclosure, loss, theft, or compromise in accordance with the above noted laws and with at least the same care employed to protect their own confidential information. Any unauthorized access, disclosure or use of this information is illegal.AST2786-01-202