COVID-19 Screening Questionnaire

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Please complete this form within 24 hours before your scheduled appointment. If your response is not received, your appointment will be cancelled. Thank you for your understanding!

Email *

First Name *

Last Name *

This questionnaire assists public health in contact tracing (when necessary) and will be kept for 14 days at which it can be destroyed in a confidential manner. *

Ok, I will answer all questions honestly and to the best of what I remember.

Are you experiencing any of the following symptoms? *

Yes

Fever (>38 ̊C) or have you felt feverish in the last 10 days

New or worsening cough?

New or worsening shortness of breath?

New or worsening difficulty breathing?

Sore throat or painful swallowing?

Runny or stuffy nose?

Loss of sense of smell, taste, or appetite?

Chills, muscle aches, or headaches?

Nausea, vomitting, or diarrhea?

Very exhausted and have a hard time waking up?

Conjunctivitis (Pink eye)

If you answered “Yes” to any of the above, you are not permitted to visit at this time and you must self-isolate. *

Ok, I understand.

Have you or anyone in your household traveled outside of Canada in the last 14 days? *

Yes

Have you or anyone in your household been in contact in the last 14 days with someone who is being investigated or confirmed to be a case of COVID-19? *

Yes

Are you currently being investigated as a suspect case of COVID-19? *

Yes

Have you ever tested positive for COVID-19? *

Yes

If you had been tested positive for COVID-19 and recovered from the symptoms, have you had additional coronavirus tests completed, which showed negative results? *

Yes

N/A - I have never tested positive for COVID-19.

Please leave non-essential personal items (ex. large bags) in your vehicle upon arrival. *

Ok, I understand.

Required

You will be provided with a brand new mask to wear and a sanitized bin to put your small personal belongings in. *

Ok, I understand

Please wait in your vehicle and text (587) 200-6388 when you have arrived. When we are ready, we will text you to come in. *

Ok, I understand.

Required

Your temperature will be taken and we will inquire about your health status again on the appointment day. If you exhibit any of the above symptoms, your service will be discontinued immediately. *

Ok, I understand.

Our beauty products can be ordered online at lashcottage.com/shop so it can be ready for pick up at your appointment.

Ok, I understand.

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We've temporarily relaxed our cancellation policy. If you need to cancel your appointment due to COVID-19 related reasons, we understand and will waive the cancellation fee. Please still let us know us at your earliest convenience at (587)200-6388 or info@lashcottage.com if you need to cancel your appointment.

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