Havens MediSpa Covid-19 Pre-Visit Screening
Dear Client. Covid-19 Pre-screen visit is a public health regulation requirement for Medical Spas. It must be completed by all clients prior to your visit. Spa services cannot be performed without completion.

Thank you | Havens MediSpa | (905) 826-7864
Sign in to Google to save your progress. Learn more
Email *
First & Last Name *
Your Appointment Date *
MM
/
DD
/
YYYY
Qsn 1: Do you have one or more of the COVID-19 symptoms below? Fever and/or chills; Cough or barking cough (croup); Shortness of breath; Sore throat; Difficulty swallowing; Decrease or loss of smell or taste; Runny or stuffy/congested nose; Headache; Nausea/vomiting; Diarrhea; Muscle aches/joint pain; Fatigue; Pink eye (for adults); Stomach pain (for adults); Falling down often (for older adults). Please note: if you received a COVID-19 vaccination in the last 48 hours and are experiencing mild headache, fatigue, muscle aches, and/or joint pain that only began after vaccination, select “No.” *
Qsn 2: Has a doctor, health care provider, or public health unit told you that you shouldcurrently be isolating (staying at home)? This can be because of an outbreak or contact tracing *
Qsn 3: In the last ten days, have you tested positive on a rapid antigen test or a home-based self-testing kit? If you have since tested negative on a lab-based PCR test, select “No". *
Qsn 4: Have you been identified as a “close contact” of someone who currently has COVID-19 in the last 14 days? If you are fully vaccinated (see note 2 below) and have not been advised to self-isolate by public health, select “No”. *
Qsn 5: Have you received a COVID Alert exposure notification on your cell phone in the last 14 days (and have not been tested or waiting for your result)? If you are fully vaccinated (see note 2 below) and/or have already gone for a test and got a negative result, select "No.
Clear selection
Qsn 6: In the last 14 days, have you traveled outside of Canada AND been advised to quarantine per the federal quarantine requirements (see link below) ? If you are not fully vaccinated (see note 2 below) and you live with someone who traveled outside of Canada. (see note 3 below)
Clear selection
Qsn 7: Is anyone you live with currently experiencing any new COVID-19 symptoms and/or waiting for test results after experiencing symptoms?If you are fully vaccinated, select “No". If the individual experiencing symptoms received a COVID-19 vaccination in the last 48 hours and is experiencing mild headache, fatigue, muscle aches, and/or joint pain that only began after vaccination, select “No.”
Clear selection
Notes (Definition, Links & Resources)
1. Federal Quarantine Requirements: https://travel.gc.ca/travel-covid#a3

2. Fully vaccinated is defined as an individual ≥14 days after receiving their second dose of a two-doseCOVID-19 vaccine series or their first dose of a one-dose COVID-19 vaccine series.

3. Effective July 5, 2021, fully vaccinated Canadians may be exempt from post-travelCOVID-19 quarantine restrictions.  For those individuals who are not fully vaccinated And either 1) live with an individual who has recently traveled outside of Canada OR 2)live with an individual who is self-isolating due to a high-risk exposure: These individuals are permitted to attend work but they are required to stay home except for essential reasons for the duration of the contact’s isolation period. Essential reasons include: attending school/child care/work and essential errands such as, obtaining groceries, attending medical appointments or picking up prescriptions.

4. If you answer YES to any one of the questions above, PLEASE DO NOT enter this location AND contact either your health care provider or Telehealth Ontario (1-866-797-0000) to get advice or an assessment, including if you need a COVID-19 test.

Health Canada definition of vulnerable individuals which would deem people to be high risk category includes:
 - People 65 years and older.

 - People of all ages with underlying medical conditions including: chronic lung disease or moderate to severe asthma, serious heart conditions, immunocompromised, severe obesity diabetes, chronic kidney disease undergoing dialysis and/or liver disease.
Service will be declined for any client with positive responses to the above or arriving showing symptoms of illness. By completing this form, you consent the information provided above by you is accurate, current and true.
Thank you for your cooperation
Havens MediSpa | (905) 826-7864
Next
Clear form
Never submit passwords through Google Forms.
This form was created inside of Havens Business Group Inc. Report Abuse
Google Forms