We Require This Form to Be Completed Prior to Your Next Appointment

To ensure the health and safety of both our patients and staff during the COVID-19 pandemic, we require the submission of a COVID-19 Patient Consent Form in order for patients and staff to attend appointments.

All patients are required to review and submit a COVID-19 Patient consent form prior to coming in for their next appointment.

PLEASE COMPLETE THE PATIENT CONSENT FORM BELOW:

* Required

CMOH Order 05-2020 legally obligates any person who has the following cough, fever, shortness of breath, runny nose, or sore throat (that is not related to a pre-existing illness or health condition) to be in isolation (quarantine) for 10 days from the start of symptoms, or until symptoms resolve, whichever takes longer. If they are exhibiting any of these symptoms, it is suggested they complete the COVID-19 Self-Assessment online tool to determine if they should be tested.

    *Patient First & Last Name:

    *Patient E-mail:

    SIGNATURE OF PATIENT

    Date Signed

    Thank you for taking the time to submit the consent form!

    Rory looks forward to helping you achieve your health and nutritional goals.
    Contact her via phone at (403) 819-6919, or via email at rory@roryrd.com to set up a consultation today!

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      Let food be thy medicine,
      thy medicine shall be thy food.

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