Coronavirus Self Declaration Form
For the health and safety of our community, declaration of illness is required. Please complete the form and be sure that the information you give is accurate and complete. Please get immediate medical attention if you have any of the COVID-19 signs.
This declaration is valid only for today's date:
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Month
-
Day
Year
Date
Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Please indicate the reason for your visit today (select all that apply)
Consultation or follow-up visit
Injectable (e.g. botox and or dermal filler)
Microneedling (e.g. Vampire PRP Facial)
Other PRP (hair, face, skin, O-Shot, P-Shot)
Venus Treatment (e.g. IPL, Diamond Polar, Viva RF microneedling)
In the past 14 days, have you experienced any of the following:
*
Yes
No
Fever over 38 °C or 100° F
Cough
Shortness of Breath
Recent loss of smell or taste
Non-allergy related runny nose
Persistent Pain in the Chest
Covid-19 Risk Assessment
Risk Assessment based on travel and contact history
Have you travelled outside British Columbia during the past two weeks?
Yes
No
Name of the area(s) visited
Country, State, City
Dates of travel
Arrival and return dates for each area
Have you been in contact with people being infected, suspected or diagnosed with COVID-19?
Yes
No
Your relationship with the people and your last contact date with them
Is there any other information about your health we should be aware of?
I acknowledge that the information which I have given on this form is accurate and complete.
Signature
Clear
Submit
Should be Empty: