Rejuvenation Health Services

COVID-19 Screening Form

Please complete the following form 24-HOURS before making an appointment.
Answer all questions.
We will contact you to confirm your appointment.
Thanks

Name*
First Name
Last Name
Email*
Phone*
(###) - ### - ####
Cough.. New or getting worse?*
Shortness of breath?*
Runny nose?*
Voice is getting horse?*
Sore throat?*
Issues swallowing?*
Lost your taste for food?*
Cannot scent smells?*
Vomiting, diarrhea, stomach pain?*
Unusual tiredness? *
Headaches?*
Cold flushes?*
Do you have a fever?*
Do you share residence or have you come in contact with anyone who has any of the above symptoms or probable case of Covid-19?*
Have you traveled outside Canada or had close contact with anyone who has traveled outside Canada?*
If you answered NO to all the questions, complete, sign and submit this form, than proceed to book your appointment.
If you answered YES to any of the questions, you MUST RESCHEDULE at another time please follow AHS protocols.
I have read, understood, and answered the preceding questions honestly?*
I understand and agree to the Personal Protection Equipment and sanitizing procedures expected of me while attending my treatment.*
I agree to report any changes in how I am feeling when I show up for my appointment.*
My signature below confirms that I assume all risks associated with my appointment and treatment.
On this Date*
At this Time*
My Authorized Signature*
Tap to sign

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COVID-19 Screening Form

If you answered NO to all the questions, complete, sign and submit this form, than proceed to book your appointment.

If you answered YES to any of the questions, you MUST RESCHEDULE at another time please follow AHS protocols.

My signature below confirms that I assume all risks associated with my appointment and treatment.