Your Name *

Have you tested positive for COVID-19 or had close contact with a confirmed case of COVID-19 without wearing appropriate PPE? *

Have you traveled outside of Canada in the past 14 days? *

Do you have any of the following symptoms: •Fever •New onset of cough •Worsening chronic cough •Shortness of breath •Difficulty breathing •Sore throat •Difficulty swallowing •Decrease or loss of sense of taste or smell •Chills •Headaches •Unexplained fatigue/malaise/muscle aches (myalgias) •Nausea/vomiting, diarrhea, abdominal pain •Pink eye (conjunctivitis) •Runny nose/nasal congestion without other known cause *

Has anyone in your household or that you have had contact with experiencing a new or worsening cough, shortness of breath, or fever? *

If you are 70 years of age or older, are you experiencing any of the following symptoms: delirium, unexplained or increased number of falls, acute functional decline, or worsening of chronic conditions? *

Do you have any reason to think you have COVID-19 or think it unsafe for you to receive massage treatment. *

To the best of your knowledge you have answered truthfully. You understand you will be screened again upon arrival at your massage appointment. You understand your RMT has, to the best of her ability, screened clients and herself, disinfected, prepared and followed Public Health and her colleges regulations to ensure your safety; but due to the nature of massage treatment can not social distance and therefore assume some risk is involved. If you, or your contacts develop any COVID-19 symptoms you will notify your RMT immediately. *

If you have answered YES to any of the above questions the RMT cannot provide treatment, regardless of the rationale for Massage Therapy treatment. Please self-isolate and complete the online self assessment too (https://covid-19.ontario.ca/self-assessment/) before calling your doctor or Telehealth Ontario at 1-866-797-0000.