Covid-19 SCREENING FORM

Before we begin your services today please read and fill out this form. Thank you :)

*IF YOU ARE UNSURE, PLEASE RESCHEDULE YOUR APPOINTMENT.

* Indicates required field

Name *

First

Last

Phone Number *

Email *

Have you, or someone you've been in contact with experienced any of the symptoms associated with COVID-19 over the past 14 days. *

I am symptom free I am NOT symptom free

Have you, and those you have been in contact with, followed current travel guidelines according to Health Canada over the past 14 days. *

Yes, I have followed travel guidelines No, I have NOT followed current travel quidelines

Have you, and those you have been in contact with, practiced current social distancing guidelines according to Health Canada over the past 14 days. *

Yes, I have followed current social distancing guidelines No, I have NOT followed current social distancing guidelines

Comment *

Submit

NEW mandatory masks in public places in St.Catharines

what-is-physical-distancing.pdf
File Size:	229 kb
File Type:	pdf

​Covid-19 SCREENING FORM