The Brow Guru: Pre-Appointment Questionnaire and Self-Assessment
The health and safety of our clients and the community is our first priority. The purpose of this questionnaire is to screen incoming clients for COVID-19 symptoms (self-assessment section), as well as to create a client visit record for contact tracing in case there is a need for you and other clients to be notified. In the event of this happening, the information provided in this form will be shared with Ottawa Public Health to support effective contact tracing. This is a necessary protocol in accordance with Ottawa Public Health and the Province of Ontario's re-opening guidelines for personal care and esthetic services (See COVID-19 response framework: keeping Ontario safe and open - for more details: https://bit.ly/3aMZYay). Please read the Liability Waiver and Consent Agreement at the end of this form.

Please fill out this questionnaire in order to complete your appointment booking. For everyone's safety, no appointments will be accepted without the completion of this form. Please also ensure that all information is accurate and filled out in full.

Complete this form immediately before arriving for your appointment.

Thank-you for your time and efforts in ensuring that we reopen as cautiously and safely as possible.

Stay #blessed,
The Brow Guru
Personal Information Section
This information will only be used or shared if the need for contact tracing becomes necessary.
Are you a New Client or a Regular Client? *
First Name *
Middle Name
Last Name *
E-mail Address *
Primary Phone Number *
Secondary Phone Number
Appointment Date *
MM
/
DD
/
YYYY
Appointment Time *
Time
:
What threading services do you require? Please select all that apply. *
Required
Self-Assessment Section
If you answer 'Yes' to any of the questions below, your pending appointment will not be confirmed.
If you answered 'Yes' to any of these questions, please return home and self-isolate.
Visit OttawaPublicHealth.ca/COVIDCentre for more information about getting tested.
If you are feeling unwell, contact your health care provider or call Telehealth Ontario at
1-866-797-0000 to speak to a registered nurse.
1. Do you have any of the following symptoms: fever/ feverish, new or existing cough and difficulty breathing? *
2. Have you travelled outside of Canada (including the United States of America) within the last 14 days? *
3. Have you had close contact with a person who has tested positive for COVID-19 or is suspected to have COVID-19? *
4. Have you had close contact with a person who has a fever, cough or shortness of breath that started within 14 days of travel outside of Canada? *
Liability Waiver and Consent Agreement
By completing this form and submitting below, you agree to accept all risk and responsibility in the case of contracting COVID-19. While we are taking every necessary and recommended safety and sanitation measure, we cannot guarantee that there is zero risk of contracting COVID-19. By completing and submitting this form, you also consent to the sharing of your information in the event that contact tracing becomes necessary. Your information will remain private otherwise.
Submit
Never submit passwords through Google Forms.
This form was created inside of The Brow Guru. Report Abuse