CovidForm | Renewal Massage

Covid-19 Health Declaration

THIS FORM CANNOT BE SUBMITTED UNLESS ALL ANSWERS ARE ENTERED. IF YOU ARE UNABLE TO CHECK A BOX THIS INDICATED THAT YOU MAY BE SYMPTOMATIC OF COVID-19 OR MAY HAVE BEEN EXPOSED TO COVID-19 AND YOU ARE NOT ELIGIBLE FOR A MESSAGE AT THIS TIME.

Full Name

Date

Current Temperature

I am NOT suffering from a fever or new / changed chronic cough and / or sore throat.

I am NOT suffering from a runny nose or nasal congestion that is not related to a known or pre-existing condition

I have NOT had any shortness of breath that is not related to a known or pre-existing condition

I have NOT traveled recently within the last 14 days outside of Canada OR I have travelled but received a negative Covid 19 test within the last 2 weeks. (Proof of negative test may be required)

I have NOT been in close contact with individuals who have a confirmed or presumptive diagnosis of COVID-19 (e.g. individuals exposed without appropiate PPE in use)

I declare that the info I’ve provided is accurate & complete

Thanks for submitting!