COVID-19 Health and Safety Form

COVID-19 Health and Safety Form
Before your appointment, please fill out this form and email/ submit your response to hello@allanadavisstudio.com.

If changes to your answers occur, please informhello@allanadavisstudio.com and reschedule your appointment until the proper precautions and measures have been taken.
Your Email
example@example.com
Have you experienced any symptoms, including coughing, congestion, fever, headache, muscle pain, shortness of breath, or a reduced sense of smell in the last 14 days?

Yes No
Have you been in contact with anyone experiencing any of these said symptoms?

Yes No
Have you travelled outside of Canada in the past month?

Yes No
Have you been in contact with anyone who has tested positive for COVID-19?

Yes No
Have you participated in any large, group activities or been in any large participatory settings in the past 15 days? (ex: parks, parties, etc.)

Yes No
Have you been in close contact with any front line workers, and if so, have you been taking safe, precautionary measures?

YES, I have been in close contact and have been taking the right measures. YES, I have been in close contact with front line workers, NO I have not taken the safe, precautionary measures. NO, I have not been in contact with any front line workers.
If you answered “YES” to any of these questions that deem you to be a risk to both studio staff and other clients, please refrain from attending your appointment and kindly reschedule in two weeks or until all safety measures have been taken.
Acknowledgement
If you answered “YES” to any of these questions that deem you to be a risk to both studio staff and other clients, please refrain from attending your appointment and kindly reschedule in two weeks or all safety measures have been taken.

Please note that if you do attend your appointment with any symptoms or having falsely answered these questions, Allana Davis, does hold the right to refuse treatment to any client if she feels uncomfortable with the situation. You will be asked to leave and reschedule for a later date.

By submitting this form, you agree to have truthfully and to the best of your ability, answered these questions.
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