Date *

MM

DD

YYYY

Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

I confirm that I am not presenting any of the following symptoms of COVID-19 identified by Saskatchewan Health Services *

Fever > 38 Degrees C

Cough

Sore Throat

Shortness of Breath

Flu-like symptoms

I confirm that I am not currently positive for the novel coronavirus. *

Yes

I verify that I have not returned to Saskatchewan from any country outside of Canada whether by car, air, bus or train in the past 14 days. *

Yes

I confirm that I am not waiting for the results of a laboratory test for the novel coronavirus. *

Yes

I understand that any travel from any country outside of Canada, including travel by car, air, bus or train, significantly increases my risk of contracting and transmitting the novel coronavirus. Saskatchewan Health Services require self-isolation for 14 days from the date a person has returned to Canada. *

Yes

I understand that Saskatchewan Health Services has asked individuals to maintain social distancing of at least 2 metres. I also understand that it is not possible to maintain this distance while receiving my treatment. *

Yes

I verify that I have not been identified as a contact of someone who has tested positive for novel coronavirus or been asked to self-isolate by Saskatchewan Health, the Communicable Disease Control or any other governmental health agency. *

Yes

I verify the information I have provided on this form is truthful and accurate. I knowingly and willingly consent to have my treatments completed at Skin Diva, during the COVID-19 pandemic. *

I Confirm and Agree