COVID-19 CUSTOMER SCREENING

DateTime
COVID-19 CUSTOMER SCREENING

Thank you for taking the time to answer these questions. The following questions follow the Ontario Government Public Health mandate in keeping Ontario safe and open [https://www.ontario.ca/page/covid-19-response-framework-keeping-ontario-safe-and-open]
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Date of your Appointment?
Please Note: You will be entering a clean and safe aesthetic clinic for personal services. Elevated cleaning and disinfection practices are in effect for clinic room and common areas in accordance with Public Health requirements, which is performed after each and every client. Practitioners time will be limited due to additional protocols needed between each client. Gloves, mask, and face shield will be worn by practiciners during your treatment.

Please observe the following:
- 6' (2 meters) self-distancing except when receiving serevices or for brief exchanges
- Hand washing or sanitizing before AND after treatment
- Please wear a MASK when coming to the clinic - or one can be purchased for $1.00
- "No Talking" policy during all close-proximity treatments when mask is off
In the last 24-48 hours prior to your appointment, have you experienced any of the following:
1. (a) Are you currently experiencing any of these symptoms? Choose any/all that are new, worsening, and not related to other known causes or conditions you already have.*

FEVER AND/OR CHILLS - (Temperature of 37.8°C or 100°F)COUGH OR BARKING COUGH(croup) - Continuous, more than usual, making a whistling noise when breathing (not related to asthma, post-infectious reactive airways, COPD, or other known causes or conditions you already have).SHORTNESS OF BREATH - Out of breath, unable to breathe deeply (not related to asthma or other known causes or conditions you already have).SORE THROAT - Not related to seasonal allergies, acid reflux, or other known causes or conditions you already have.DIFFICULTY SWALLOWING - Painful swallowing (not related to other known causes or conditions you already have).RUNNY OR STUFFY/CONGESTED NOSE - Not related to seasonal allergies, being outside in cold weather, or other known causes or conditions you already have.DECREASE OR LOSS OF TASTE OR SMELL - Not related to seasonal allergies, neurological disorders, or other known causes or conditions you already have.PINK EYE - Conjunctivitis (not related to recurring styes or other known causes or conditions you already have).Headache - Unusual, long-lasting (not related to tension-type headaches, chronic migraines, or other known causes or conditions you already have).DIGESTIVE ISSUES LIKE NAUSEA/VOMITING, DIARRHEA, STOMACH PAIN - Not related to irritable bowel syndrome, menstrual cramps, or other known causes or conditions you already have.MUSCLE ACHES - Unusual, long-lasting (not related to a sudden injury, fibromyalgia, or other known causes or conditions you already have).EXTREME TIREDNESS - Unusual, fatigue, lack of energy (not related to depression, insomnia, thyroid dysfunction, or other known causes or conditions you already have).NONE OF THE ABOVEOther
1. (b) If over age 70, are you experiencing any of the following?*

DELIRIUMUNEXPLAINED OR INCREASED NUMBER OF FALLSACUTE FUNCTIONAL DECLINEWORSENING OF CHRONIC CONDITIONSNONE OF THE ABOVEOther
2. Is anyone you live with currently experiencing any new COVID-19 symptoms and or waiting for test results after experiencing symptoms?*

YesNo
3. In the last 14 days, have you or anyone you live with travelled outside of Canada?*

YesNo
4. In the last 14 days, have you been identified as a "close contact" of someone who currently has COVID-19?*

YesNo
5. Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)?*

YesNo
6. In the last 14 days, have you received a COVID alert exposure notification on your cell phone? (If you already went for a test and got a negative result, select "No".)*

YesNo
If YES to any of the questions above, you cannot be treated today and it would be best for you to see a doctor to be cleared.
I verify the information I have provided on this form is truthfull and accurate. I knowingly and willingly consent to receive treatment during the COVID-19 pandemic and in relation to current Canadian Government Guidelines regarding COVID-19 and pandemic, I acknowledge and accept the risks that I could be exposed to COVID-19 during the provision of services from any Public Venue including CONFIDENT IMAGE CHEZ FRANCE. I understand that I need to inform France Di Paola immediately, should I test positive for COVID-19 within 14 days from my treatment date.
If you consent to all of the above, please sign here:*

Clear
Confident Image Chez France - 36 Hiscott St. Unit 100B, St. Catharines, ON L2R 1C8

(905) 931-0686 - info@confidentimage.ca www.confidentimagechezfrance.com
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