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Health Declaration

Please fill out the following health declaration the same day prior to your service. Thank you kindly.

First Name

Last Name

Email

Phone

Time of appointment?

Check off Only if you Haven't any of the following, * Required

I Do Not have a sore throat, or trouble swallowing

I Do Not have a runny nose/stuffy nose or nasal congestion

I Do Not have a decrease or loss of smell or taste

I Have NOT travelled outside of Canada in the past 14 days

I Have Not been in close contact with a confirmed or probable case of COVID-19

Date

Initials

I confirm that the information given in this form is true

Thanks for submitting!

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