COVID-19 Screening Questionnaire
Please complete this form within 24 hours before your scheduled appointment. If your response is not received, your appointment will be cancelled. Thank you for your understanding!
Email address *
First Name *
Last Name *
This questionnaire assists public health in contact tracing (when necessary) and will be kept for 14 days at which it can be destroyed in a confidential manner. *
Are you experiencing any of the following symptoms? *
Fever (>38 ̊C) or have you felt feverish in the last 10 days
New or worsening cough?
New or worsening shortness of breath?
New or worsening difficulty breathing?
Sore throat or painful swallowing?
Runny or stuffy nose?
Loss of sense of smell, taste, or appetite?
Chills, muscle aches, or headaches?
Nausea, vomitting, or diarrhea?
Very exhausted and have a hard time waking up?
Conjunctivitis (Pink eye)
If you answered “Yes” to any of the above, you are not permitted to visit at this time and you must self-isolate. *
Have you or anyone in your household traveled outside of Canada in the last 14 days? *
Have you or anyone in your household been in contact in the last 14 days with someone who is being investigated or confirmed to be a case of COVID-19? *
Are you currently being investigated as a suspect case of COVID-19? *
Have you ever tested positive for COVID-19? *
If you had been tested positive for COVID-19 and recovered from the symptoms, have you had additional coronavirus tests completed, which showed negative results? *
Please leave non-essential personal items (ex. large bags) in your vehicle upon arrival. *
You will be provided with a brand new mask to wear and a sanitized bin to put your small personal belongings in. *
Please wait in your vehicle and text (587) 200-6388 when you have arrived. When we are ready, we will text you to come in. *
Your temperature will be taken and we will inquire about your health status again on the appointment day. If you exhibit any of the above symptoms, your service will be discontinued immediately. *
Please order lash serum / retail products online at so your order can be packaged and ready for pick up at your appointment. Use coupon code 'LASHCLIENT' for 15% off your whole order.
Clear selection
We've temporarily relaxed our cancellation policy. If you need to cancel your appointment due to COVID-19 related reasons, we understand and will waive the cancellation fee. Please still let us know us at your earliest convenience at (587)200-6388 or if you need to cancel your appointment.
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy