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GOOD NEWS
We offer service in your area!

Call us or fill out the referral form below and you are one step closer to be assigned a guardian angel
Intake Form
Referring a Participant, Client or Patient
Client/ Participant's Details
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Referrer's Details *
Services Details

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Covid 19

Covid 19 screening question
This mandatory screening is to protect the health of our patients and Northern Pain Centre Personnel Please Circle Yes or No

1. Do you have a fever or Respiratory Symptoms? Yes No Symptoms include fever OR an acute respiratory infection and include (but are not limited to) cough, sore throat, fatigue and shortness of breath with or without a fever. Required
2. Have you been identified as a close contact of a confirmed case of novel coronavirus? Yes No A close contact is someone who has been face to face for at least 15 minutes, or been in the same closed space for at least 2 hours, as someone who has tested positive for the COVID-19 when that person was infectious Required
3. Have you returned from overseas or covid 19 hotspot within the last 14 days? Required
5. Have you been asked to self-isolate by your GP, or a government authority? Required
4. Are you waiting on COVID-19 swab results? Required
Declaration, Please tick the I declare button to declare that the above information is true Required
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