COVID-19 Health Screening - Carolyns Model & Talent Agency

Instructions:

In order to ensure the health and safety of our staff, clients, and community, it is important that all those planning on coming in for an in-person appointment go through screening steps to ensure they are appropriate for in-person appointments at this time. We ask that before every in-person appointment clients please fill out the following form. This form should be filled out 24 hours before your appointment to ensure that answers given are still valid. Please note this form must be submitted prior to your appointment. Failure to do so will prohibit appointments from entering the Agency and may result in the loss of appointment. If you have any questions or concerns regarding this form please contact the agency at info@carolynsonline or 905-542-8885.

Name *

First

Last

Child Name *

Email *

Phone *

Scheduled Appointment Date *

Date

Time

Have you or anyone in your household traveled outside of Canada in the last 14 days? *

Did you provide care for or have close contact with a person with COVID-19? Probable or confirmed. *