Havens MediSpa Covid-19 Pre-Visit Screening
Dear Client. Covid-19 Pre-screen visit is a public health regulation requirement for Medical Spas. It must be completed by all clients prior to your visit. Spa services cannot be performed without completion.

Thank you | Havens MediSpa | (905) 826-7864
Email *
First & Last Name *
Your Appointment Date *
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Have you tested positive for COVID-19, or been in contact with someone who has in the past 14 days? *
Have you been tested for COVID-19 and are currently awaiting the test results? *
Do you have any of the following symptoms: fever, dry cough, body aches, headaches, sore throat, shortness of breath, loss of taste and/or smell, diarrhea? *
Are you or your immediate contacts in a high-risk category? *
Health Canada definition of vulnerable individuals which would deem people to be high risk category includes:
- People 65 years and older.

- People of all ages with underlying medical conditions including: chronic lung disease or moderate to severe asthma, serious heart conditions, immunocompromised, severe obesity diabetes, chronic kidney disease undergoing dialysis and/or liver disease.
Service will be declined for any client with positive responses to the above or arriving showing symptoms of illness. By completing this form, you consent the information provided above by you is accurate, current and true.
Thank you for your cooperation
Havens MediSpa | (905) 826-7864
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