KEANNASLASH: COVID-19 SCREENING & ACKNOWLEDGMENT FORM

For individuals who are 18 years of age and older:

Do you have any one or more of the following symptoms?

YesNo

Fever and/or chills: Temperature of 37.8 degrees Celsius/100 degrees Fahrenheit or higher

Cough or barking cough (croup): Not related to asthma, post-infectious reactive airways, COPD, orother known causes or conditions you already have

Shortness of breath: 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 youalready have

Difficulty swallowing: Painful swallowing (not related to other known causes or conditions youalready have)

Decrease or loss of smell or taste: Not related to seasonal allergies, neurological disorders, or otherknown causes or conditions you already have

Pink eye Conjunctivitis: (not related to reoccurring styes or other known causes or conditions youalready have)

Runny or stuffy/congested nose: Not related to seasonal allergies, being outside in cold weather, orother known causes or conditions you already have

Headache: Unusual, long-lasting (not related to tension-type headaches, chronic migraines, or otherknown causes or conditions you already have)

Digestive issues like nausea/vomiting, diarrhea, stomach pain: Not related to irritable bowelsyndrome, 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 knowncauses or conditions you already have)

Extreme tiredness: Unusual, fatigue, lack of energy (not related to depression, insomnia, thyroiddysfunction, or other known causes or conditions you already have)

Falling down often: For older people

For individuals who are under 18 years of age:

Do you have one or more of the following symptoms?

YesNo

Fever and/or chills: Temperature of 37.8 degrees Celsius/100 degrees Fahrenheit or higher

Cough or barking cough (croup): Continuous, more than usual, making a whistling noise whenbreathing (not related to asthma, post-infectious reactive airways, or other known causes orconditions you already have)

Shortness of breath: Out of breath, unable to breathe deeply (not related to asthma or otherknown causes or conditions you already have)

Decrease or loss of smell or taste: Not related to seasonal allergies, neurological disorders, orother known causes or conditions you already have

Sore throat or difficulty swallowing: Painful swallowing (not related to seasonal allergies, acidreflux, or 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

Headache: Unusual, long-lasting (not related to tension-type headaches, chronic migraines, orother known causes or conditions you already have)

Nausea, vomiting and/or diarrhea: Not related to irritable bowel syndrome, anxiety, menstrualcramps, or other known causes or conditions you already have

Extreme tiredness or muscle aches: Unusual, fatigue, lack of energy (not related to depression,insomnia, thyroid dysfunction, sudden injury, or other known causes or conditions you alreadyhave)

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

YesNo

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

YesNo

In the last 14 days, have you received a COVID Alert exposure notification on your cellphone? If you already went for a test and got a negative result, select "No."

YesNo

In the last 14 days, have you or anyone you live with travelled outside of Canada? If you oranyone you live with are exempted from federal quarantine as per Group Exemptions,Quarantine Requirements under the Quarantine Act, select “No”.

YesNo

In the last 14 days, have you been to any large gatherings? (Parties, night clubs, etc.)

YesNo

Is anyone you live with currently experiencing any new COVID-19 symptoms and/or waitingfor test results after experiencing symptoms?

YesNo

Results of Screening Questions:

• If the patron answered NO to all questions from 1 through 6, they can enter the business or organization.

• If the patron answered YES to any questions from 1 through 6, they should not enter the business or organization(including any outdoor or partially outdoor business or facility). They should be advised to go home to self-isolateimmediately and contact their health care provider or Telehealth Ontario (1-866-797-0000) to get advice or anassessment, including if they need a COVID-19 test.

• If the patron answered YES to question 6, they must be advised to stay home until the sick individual gets anegative COVID-19 test result, is cleared by their local public health unit, or is diagnosed with another illness.

• If any of the answers to these screening questions change during the day, this screening result is no longer validand the patron may need to screen again, wherever necessary.

• Any record created as part of patron screening may only be disclosed as required by law.

I am aware that if I exhibit any symptoms of COVID-19 or appear unwell, the tech can, at anymoment during my appointment, cancel all procedures and send me home.

Client Initials*

I understand that Eyelash Enhancing Services are intimate procedures and I am aware of theheightened risk of exposure to COVID-19.

Client Initials*

Client Name:

First NameLast Name

Today's Date:

Date

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