COVID PRE-SCREENING – Jolantas European Spa Forms

FirstName

LastName

Have you been experiencing any of the following symptoms ?

1. Coughing?

Yes

2. Nasal congestion or runny nose?

Yes

3. Sore Throat?

Yes

4. Fever above 38 degrees Celsius?

Yes

5. Headache?

Yes

6. Muscle Pain?

Yes

7. Shortness of breath or difficulty breathing?

Yes

8. Loss or reduced sense of taste or smell?

Yes

In the last 2 weeks:

9. Have you been in contact with someone experiencing symptoms?

Yes

10. Have you been in contact with someone who appears to have COVID-19?

Yes

11. Have you been in contact with someone who has been diagnosed with COVID-19?

Yes

12. Have you travelled outside Canada in the last two weeks?

Yes

If you answer yes to any of these questions, we will
ask you to postpone your appointment for 4 weeks. As
well if you appear to have symptoms after
appointment please contact us.
By signing you acknowledge you have read all of the
above questions and truthfully answered.

Signature

Clear

Date

If you are human, leave this field blank.

COVID-19 PRE-SCREENING