COVID-19 | Wellness Acupuncture

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Mandatory COVID-19 Waiver/Screening

Mandated by Ontario Ministry of Health and TCMPAO. To prevent the spread of COVID-19 and reduce the potential risk of exposure to our workforce and visitors, we are conducting a simple screening questionnaire. Your participation is important and required

First Name

Last Name

I received my final (or second) vaccination dose more than 14 days ago? *A fully immunized individual is defined as any individual >14 days after receiving their second dose of a two-dose COVID-19 vaccine series or their first dose of a one-dose COVID-19 vaccine series

I declare to have none of the following symptoms: fever/chills; new onset of cough or worsening of the chronic cough; shortness of breath; decrease or loss of sense of taste/smell; lethargy or fatigue; muscle aches

I haven't been tested POSITIVE for Covid-19 in the past 10 days

I haven't been told to self-isolate

I haven't travelled outside of Canada in the past 14 days

I haven't had close contact with confirmed case of COVID-19 without wearing appropriate PPE

I agree to wear a mask at the time of my appointment

I declare that the info I’ve provided is accurate & complete

Initials

Date

Thanks for submitting!

Wellness Acupuncture Clinic

Giving your body the health & wellness it deserves

Mandatory COVID-19 Waiver/Screening