COVID-19 Consent Form
Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
I knowingly and willingly consent to service(s) at Grace&Glow during this time
Have you been tested for COVID-19 in the last 14 days?
Do you have any of the following symptoms?
Fever
New onset of cough
Worsening chronic cough
Shortness of breath
Difficulty breathing
Sore throat
Difficulty swallowing
Decrease or loss of sense of taste or smell
Chills
Headaches
Unexplained fatigue/malaise/muscle aches
Nausea/vomiting
Abdominal pain
Pink eye (conjunctivitis)
Diarrhea
Runny nose/nasal congestion without other know causes
No Symptoms
Other
Have you been in contact with anyone with acute respiratory illness/ COVID-19 in the last 14 days
Have you been in contact with anyone with the above symptoms in the last 14 days?
Have you travelled outside of Canada in the last 14 days
Have you been asked by Public Health, Doctor or Health Care Provider to self isolate within the last 14 days?
If you have tested positive for COVID-19 in the past when was the test and when was the date you were cleared? If you have not tested positive just type no.
In the last 14 days have you received a COVID-19 alert on your phone?
Do you or anyone in your bubble work in a long term care facility or nursing home?
Has your school or place of work recently had a COVID-19 outbreak or an increase in cases?
I understand that Grace&Glow is beauty studio which means I will be coming into their studio to provide the service(s)
Yes
No
Are you currently taking any medications?
Yes
No
I can confirm that I have not travelled domestically within Canada by commercial airline, train or bus within the last 14 days
Yes
No
Do you have any medical conditions we should be made aware of prior to your appointment?
Is there anything we should be made aware of? Please be specific
Symptom Screening
Please be advised we have the right to check all clients temperatures if deemed necessary We will be checking temperature as well as a pulse and oxygen saturation level prior to starting your appointment Please be advised that if you are showing any signs/symptoms of being sick and/or unwell we have the right to refuse the service and reschedule at a later date
Terms & Conditions
I understand, read and completed this form truthfully and to the best of my ability. I agree that this constitutes full disclosure and that it supersedes any previous verbal or written disclosures. I understand by signing this document, I am waiving the right to file for any claims, losses or damages of any kind. I understand this document is to provide the best possible guest experience when Grace&Glow provides a mobile service
Signature
Submit
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