COVID-19 SCREENING | Alex Massage & TCM Wellness Clinic

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Alex Massage & TCM Wellness Clinic

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Covid-19 Screening Questions

*Please fill this form prior to your scheduled appointment.

First Name

Last Name

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

I haven’t been in close contact with a confirmed case of Covid-19 in the last 14 days

I am not experiencing the symptoms: fever, new onset of cough, shortness of breath, sore throat, decreased sense of taste or smell.

Date of Scheduled Appointment

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

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