Long COVID Intake Form

Welcome to our intake form for members who are experiencing Long COVID.

The intake process involves you providing CC TeleHealth with health details through which we can better understand your health challenges. As you know, Long COVID is a very complex health challenge often experienced after the COVID-19 virus has been destroyed. We believe CC TeleHealth provides a quality treatment for Long COVID that is very rare. 

Long COVID Treatment is Available in the Following Canadian Provinces:

  • Ontario
  • Manitoba
  • Nova Scotia
  • Newfoundland & Labrador

Assessment Forms

The following forms will need to be completed and will be used as part your intake process:

  1. LONG COVID INTAKE FORM: (this form) providing us with history of general health, COVID-19 and Long COVID;
  2. INFORMED CONSENT:  providing clarification of the science and practices we utilize and your agreement to be treated based on our approach to science and developing treatment practices;
  3. LONG COVID CONDITIONS ASSESSMENT TOOL: used for assessing and tracking the severity of health conditions you are experiencing;
  4. 2-DAY NUTRITIONAL TRACKING FORM: Designed to track your diet and how it could be affecting your health.

Please recognize that the more we know about you, the better we are able to help. 
We look forward to assisting you in the treatment of Long COVID.