Full Circle Bodyworks

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

COVID-19 Self Assessment and Informed Consent to Receive Treatment Form

Email *

Full Circle Bodyworks is taking special care with the intake of each individual. Please complete this questionnaire prior to your appointment. Thank you!

This self assessment tool, developed with the BC Ministry of Health, will help determine whether you may need further assessment for COVID-19 testing by a healthcare provider or at a local collection center.

1. Are you experiencing any of the following? *

Severe difficulty breathing (e.g. struggling to breathe or speaking in single words)

Severe chest pain

Have a very hard time waking up

Feeling confused

Losing consciousness

None of the above

Required

2. Are you experiencing any of the following? *

Mild to moderate shortness of breathe

Inability to lie down because of difficulty breathing

Chronic health conditions that you are having difficulty managing because of difficulty breathing

None of the above

Required

3. Are you experiencing cold, flu or COVID-19 like symptoms, EVEN MILD ONES? (Symptoms include: fever, chills, cough, shortness of breath, sore throat and painful swallowing, stuffy or runny nose, loss of sense of smell, headache, muscle aches, fatigue or loss of appetite.) *

Yes

4. Have you traveled to any countries outside Canada (including the United States) within the last 14 days? *

Yes

5. Did you provide care or have close contact with a person with confirmed COVID-19? (Note: This means you would have been contacted by your health authority's public health team.) *

Yes

Informed consent to receive treatment.

I understand that my appointment will be cancelled immediately if I “the client” do not meet the pre-screening criteria upon physical presentation at the clinic.

I understand that while Hayley Clarke of Full Circle Bodyworks Inc. is following all of the health and safety guidelines outlined by the Shiatsu Therapist Association of BC, and the Provincial Health Officer and is taking all reasonable precautions to mitigate risk, there are no guarantees that I may not come into contact with COVID-19.

By signing this form, I acknowledge that I am aware of the risks involved and give consent to receive treatment.

Date: *

Signature: *

Send me a copy of my responses.

Submit

Clear form

Never submit passwords through Google Forms.

reCAPTCHA

Privacy Terms

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms