Confirmation of your Appointment with Patricia Beretta,
and Simplified Screening for Covid-19

THANK YOU IN ADVANCE FOR ANSWERING THE QUESTIONS BELOW,
And submitTING this form WHEN YOU RECEIVE YOUR APPOINTMENT REMINDER
(which is emailed to you 2 to 4 days before your appointment).

Questions followed by a “*” must be answered in order to be able to submit this form, thank you.

The “Submit” button is at the bottom of the form.

We kindly remind you that every one is wearing a mask inside the Courtland Acupuncture clinic.
We see patients with a compromised immune system, and take every measure to protect them. Thank you for your understanding.
Please bring a clean or new mask, but don’t worry, we’ll have a new mask ready for you, just in case.

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Payment methods:
we take all payment cards, but would appreciate if you could pay with debit
(when you pay with credit, it is quite expensive for us as a small business).
you can pay by DEBIT, e-transfer, cash, or cheque. Thank you.

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A reminder of our cancelation policy can be found just after the Submit button below

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48 HOUR CANCELATION POLICY:

We send email reminders as a courtesy.
WE WOULD LIKE TO KINDLY REMIND YOU THAT WE HAVE A 48 HOURS CANCELATION POLICY
(whether you received the reminder or not)

Of course, if you are sick, have a family or work emergency, or in case of inclement weather, we will waive the cancelation fee, and we will not charge you for the missed appointment.
To be honest, I can’t remember when I charged anyone for missing an appointment, so no worry!

If you know you need to change an appointment, we appreciate hearing about it as early as you can notify us. One the one hand, it is not always easy to fill a cancelation, and on the other hand, a number of people may have enjoyed taking the appointment, if they’d known early enough. Thank you for your understanding.

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COVID SCREENING

If you screen negative, whatever your vaccination status, we will be happy to see you. We fully respect your choices with respect to vaccination. We feel that our disinfection procedures, and use of PPE can keep every one safe. But for everyone’s safety, we do ask that you notify us asap if you have symptoms or any doubt of a possible exposure to covid. We will assess the situation and discuss it with you. We may have to re-schedule your appointment to be on the safe side.
We appreciate your understanding.

Your screening for covid is positive if one of any of the following items applies to you:
- You have experienced one of the following unusual symptoms in the past 10 days: Fever and/or chills, Cough, Shortness of breath / difficulty breathing, Decrease or loss of taste or smell, Muscle aches / joint pain, Fatigue, Sore throat, Runny or stuffy / congested nose, Headache, Nausea / vomiting, and/or diarrhea
- In the last 14 days, have you travelled outside of Canada AND are currently required to be in quarantine per the federal quarantine requirements
- A doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)
- In the last 10 days, have you been in close contact with someone who has tested positive for COVID-19 or has symptoms consistent with COVID-19
- You live with someone who is currently isolating because of Covid-19
- In the last 10 days, have you tested positive for Covid-19.

If you are sick with any acute illness (Cold, Flu, Stomach Bug or COVID-19) you should stay home until all of the following apply to you:

  • your symptoms have been improving for at least 24 hours (or 48 hours if you had nausea, vomiting and/or diarrhea)  

  • you do not have a fever

  • you do not develop any additional symptoms

Here are are resources if you are in doubt or if you think you may have Covid-19:

  • Fill the online self-evaluation questionnaire https://covid-19.ontario.ca/self-assessment/

  • Call your Doctor, or call Ontario Telehealth at 1-866-797-0000 or the Region of Waterloo Public Health and Emergency Services 519-575-4400. If you are very unwell, and have difficulty breathing, call 911.

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