MANDATORY HEALTH SCREENING Please complete the form below upon arrival at Rejuve-Nation Wellness Experts Name * First Name Last Name Phone (###) ### #### Are you experiencing any of the following symptoms? * - a new or worsening cough - shortness of breath - feeling feverish - chills - fatigue or weakness - muscle or body aches - headache - new loss of smell or taste - gastrointestinal symptoms (abdominal pain, diarrhea, vomiting) - feeling very unwell Yes No Has anyone in your household experienced any symptoms in the past 14 days? * Note: if the symptomatic person in your household has received a negative COVID-19 test result, please answer 'no' Yes No In the past 14 days, have you been identified as a close contact of someone with suspected or confirmed COVID-19? Yes No Have you travelled outside of Canada in the past 14 days or been in contact with someone who has travelled outside of Canada in the past 14 days? Yes No If yes is answered to any of the questions above: Please do not enter the building. Have you received all the necessary vaccines? Yes No I choose to not disclose my medical information Proof of vaccination along with photo ID to access some of our services may be required for Ontario Public Health Authorities I can and will provide these documents upon request I can and will provide a legal exception document upon request I do not comply and understand that refusal may result in denied entry to the premises and/or potential fines from Ontario Law Enforcement. Thank you!
