Intake Screening Form

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- Intake Screening Form
Services
About me
Tips

Massage Therapy in STITTSVILLE, ON

613-836-0033

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COVID-19 Screening

Please complete the screening form before booking.

Name(*)

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Email Address(*)

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Phone Number(*)

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Have you traveled in the past 14 days?(*)

YES
NO
I am double vaccinated and this does not apply to me.

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Are you feeling UNWELL, or have a family member who's feeling UNWELL(*)

YES
NO

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I have had contact with some with COVID-19, or who has had COVID-19(*)

YES
NO

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I have a COMPROMISED IMMUNE SYSTEM

YES
NO Invalid Input

I have had a COUGH or FEVER in the past 14 DAYS

YES
NO Invalid Input

In accordance with Public Health measures, we ask that you not travel between zones, especially when coming from or going to a red zone. Do you confirm you are in compliance with Public health regulations ?(*)

Yes
No

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I am taking every precaution to minimize the risk.

You must wear a mask for the massage I will wear a mask for the massage.

By booking your appointment, you are agreeing that Jennifer Sheehan RMT holds no liability if you contact COVID-!9 during your visit. (*)

I accept

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Based on the information provided your risk factors are high. Please contact me by email for more information, or self isolate for 14 days and try again.

Thank you

Get Directions

Address

1495 Stittsville Main St,
Stittsville, Ontario K2S 1V5

Phone

613-836-0033

Email

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