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Self-Assessment Questionnaire

Our team is devoted to the safety and well-being of our employees and guests. We therefore ask you to please complete the following questionnaire prior to your service to help us to try to attain the safest possible environment for all those concerned.

If you answer YES to any of these questions, PLEASE do not proceed with your service.

First Client's Name

First Name*

Last Name*

Phone*
First Client's Date of Birth*
I certify that I am 18 years of age or older
First Client's Information
1. Are you experiencing any of the following symptoms?*
a. Severe difficulty breathing (deeply struggling for breath, can only speak in single words)
b. Severe chest pain
c. Difficult time waking up
d. Feeling confusion
e. Loss of consciousness
f. None

IF YOU ANSWERED CIRCLED ANY OF THE ABOVE, IMMEDIATELY CALL 911 OR GO DIRECTLY TO THE NEAREST EMERGENCY DEPARTMENT.

2. Are you experiencing any of the following symptoms?*
a. Difficulty breathing (struggling for breath, cannot hold breath for 10 seconds)
b. A fever
c. New cough
d. None
3. Are you experiencing any of the following symptoms that are not directly related to a known cause, i.e. arthritis, allergies, or recent injury?*
a. Muscle aches
b. Fatigue
c. Headache
d. Sore throat
e. Runny nose
f. None
4. Have you travelled outside of Canada in the last 14 days?*
Yes
No
5. In the last 30 days, have you been in contact with someone who is sick with respiratory symptoms (fever, cough, difficulty breathing) and who has recently travelled outside of Canada?*
Yes
No
6. In the last 30 days, have you been in contact with someone who has been diagnosed with COVID-19?*
Yes
No

We request that you please follow our infection control protocols during your visit with us. This will require hand hygiene, masks, etc.

Thank you for helping us during this difficult time.


Date of Service
First Client's Signature*
Second Client's Name

First Name*

Last Name*
Second Client's Date of Birth*
Second Client's Information
1. Are you experiencing any of the following symptoms?*
a. Severe difficulty breathing (deeply struggling for breath, can only speak in single words)
b. Severe chest pain
c. Difficult time waking up
d. Feeling confusion
e. Loss of consciousness
f. None

IF YOU ANSWERED CIRCLED ANY OF THE ABOVE, IMMEDIATELY CALL 911 OR GO DIRECTLY TO THE NEAREST EMERGENCY DEPARTMENT.

2. Are you experiencing any of the following symptoms?*
a. Difficulty breathing (struggling for breath, cannot hold breath for 10 seconds)
b. A fever
c. New cough
d. None
3. Are you experiencing any of the following symptoms that are not directly related to a known cause, i.e. arthritis, allergies, or recent injury?*
a. Muscle aches
b. Fatigue
c. Headache
d. Sore throat
e. Runny nose
f. None
4. Have you travelled outside of Canada in the last 14 days?*
Yes
No
5. In the last 30 days, have you been in contact with someone who is sick with respiratory symptoms (fever, cough, difficulty breathing) and who has recently travelled outside of Canada?*
Yes
No
6. In the last 30 days, have you been in contact with someone who has been diagnosed with COVID-19?*
Yes
No

We request that you please follow our infection control protocols during your visit with us. This will require hand hygiene, masks, etc.

Thank you for helping us during this difficult time.


Date of Service
Third Client's Name

First Name*

Last Name*
Third Client's Date of Birth*
Third Client's Information
1. Are you experiencing any of the following symptoms?*
a. Severe difficulty breathing (deeply struggling for breath, can only speak in single words)
b. Severe chest pain
c. Difficult time waking up
d. Feeling confusion
e. Loss of consciousness
f. None

IF YOU ANSWERED CIRCLED ANY OF THE ABOVE, IMMEDIATELY CALL 911 OR GO DIRECTLY TO THE NEAREST EMERGENCY DEPARTMENT.

2. Are you experiencing any of the following symptoms?*
a. Difficulty breathing (struggling for breath, cannot hold breath for 10 seconds)
b. A fever
c. New cough
d. None
3. Are you experiencing any of the following symptoms that are not directly related to a known cause, i.e. arthritis, allergies, or recent injury?*
a. Muscle aches
b. Fatigue
c. Headache
d. Sore throat
e. Runny nose
f. None
4. Have you travelled outside of Canada in the last 14 days?*
Yes
No
5. In the last 30 days, have you been in contact with someone who is sick with respiratory symptoms (fever, cough, difficulty breathing) and who has recently travelled outside of Canada?*
Yes
No
6. In the last 30 days, have you been in contact with someone who has been diagnosed with COVID-19?*
Yes
No

We request that you please follow our infection control protocols during your visit with us. This will require hand hygiene, masks, etc.

Thank you for helping us during this difficult time.


Date of Service
Fourth Client's Name

First Name*

Last Name*
Fourth Client's Date of Birth*
Fourth Client's Information
1. Are you experiencing any of the following symptoms?*
a. Severe difficulty breathing (deeply struggling for breath, can only speak in single words)
b. Severe chest pain
c. Difficult time waking up
d. Feeling confusion
e. Loss of consciousness
f. None

IF YOU ANSWERED CIRCLED ANY OF THE ABOVE, IMMEDIATELY CALL 911 OR GO DIRECTLY TO THE NEAREST EMERGENCY DEPARTMENT.

2. Are you experiencing any of the following symptoms?*
a. Difficulty breathing (struggling for breath, cannot hold breath for 10 seconds)
b. A fever
c. New cough
d. None
3. Are you experiencing any of the following symptoms that are not directly related to a known cause, i.e. arthritis, allergies, or recent injury?*
a. Muscle aches
b. Fatigue
c. Headache
d. Sore throat
e. Runny nose
f. None
4. Have you travelled outside of Canada in the last 14 days?*
Yes
No
5. In the last 30 days, have you been in contact with someone who is sick with respiratory symptoms (fever, cough, difficulty breathing) and who has recently travelled outside of Canada?*
Yes
No
6. In the last 30 days, have you been in contact with someone who has been diagnosed with COVID-19?*
Yes
No

We request that you please follow our infection control protocols during your visit with us. This will require hand hygiene, masks, etc.

Thank you for helping us during this difficult time.


Date of Service
Fifth Client's Name

First Name*

Last Name*
Fifth Client's Date of Birth*
Fifth Client's Information
1. Are you experiencing any of the following symptoms?*
a. Severe difficulty breathing (deeply struggling for breath, can only speak in single words)
b. Severe chest pain
c. Difficult time waking up
d. Feeling confusion
e. Loss of consciousness
f. None

IF YOU ANSWERED CIRCLED ANY OF THE ABOVE, IMMEDIATELY CALL 911 OR GO DIRECTLY TO THE NEAREST EMERGENCY DEPARTMENT.

2. Are you experiencing any of the following symptoms?*
a. Difficulty breathing (struggling for breath, cannot hold breath for 10 seconds)
b. A fever
c. New cough
d. None
3. Are you experiencing any of the following symptoms that are not directly related to a known cause, i.e. arthritis, allergies, or recent injury?*
a. Muscle aches
b. Fatigue
c. Headache
d. Sore throat
e. Runny nose
f. None
4. Have you travelled outside of Canada in the last 14 days?*
Yes
No
5. In the last 30 days, have you been in contact with someone who is sick with respiratory symptoms (fever, cough, difficulty breathing) and who has recently travelled outside of Canada?*
Yes
No
6. In the last 30 days, have you been in contact with someone who has been diagnosed with COVID-19?*
Yes
No

We request that you please follow our infection control protocols during your visit with us. This will require hand hygiene, masks, etc.

Thank you for helping us during this difficult time.


Date of Service
Sixth Client's Name

First Name*

Last Name*
Sixth Client's Date of Birth*
Sixth Client's Information
1. Are you experiencing any of the following symptoms?*
a. Severe difficulty breathing (deeply struggling for breath, can only speak in single words)
b. Severe chest pain
c. Difficult time waking up
d. Feeling confusion
e. Loss of consciousness
f. None

IF YOU ANSWERED CIRCLED ANY OF THE ABOVE, IMMEDIATELY CALL 911 OR GO DIRECTLY TO THE NEAREST EMERGENCY DEPARTMENT.

2. Are you experiencing any of the following symptoms?*
a. Difficulty breathing (struggling for breath, cannot hold breath for 10 seconds)
b. A fever
c. New cough
d. None
3. Are you experiencing any of the following symptoms that are not directly related to a known cause, i.e. arthritis, allergies, or recent injury?*
a. Muscle aches
b. Fatigue
c. Headache
d. Sore throat
e. Runny nose
f. None
4. Have you travelled outside of Canada in the last 14 days?*
Yes
No
5. In the last 30 days, have you been in contact with someone who is sick with respiratory symptoms (fever, cough, difficulty breathing) and who has recently travelled outside of Canada?*
Yes
No
6. In the last 30 days, have you been in contact with someone who has been diagnosed with COVID-19?*
Yes
No

We request that you please follow our infection control protocols during your visit with us. This will require hand hygiene, masks, etc.

Thank you for helping us during this difficult time.


Date of Service
Seventh Client's Name

First Name*

Last Name*
Seventh Client's Date of Birth*
Seventh Client's Information
1. Are you experiencing any of the following symptoms?*
a. Severe difficulty breathing (deeply struggling for breath, can only speak in single words)
b. Severe chest pain
c. Difficult time waking up
d. Feeling confusion
e. Loss of consciousness
f. None

IF YOU ANSWERED CIRCLED ANY OF THE ABOVE, IMMEDIATELY CALL 911 OR GO DIRECTLY TO THE NEAREST EMERGENCY DEPARTMENT.

2. Are you experiencing any of the following symptoms?*
a. Difficulty breathing (struggling for breath, cannot hold breath for 10 seconds)
b. A fever
c. New cough
d. None
3. Are you experiencing any of the following symptoms that are not directly related to a known cause, i.e. arthritis, allergies, or recent injury?*
a. Muscle aches
b. Fatigue
c. Headache
d. Sore throat
e. Runny nose
f. None
4. Have you travelled outside of Canada in the last 14 days?*
Yes
No
5. In the last 30 days, have you been in contact with someone who is sick with respiratory symptoms (fever, cough, difficulty breathing) and who has recently travelled outside of Canada?*
Yes
No
6. In the last 30 days, have you been in contact with someone who has been diagnosed with COVID-19?*
Yes
No

We request that you please follow our infection control protocols during your visit with us. This will require hand hygiene, masks, etc.

Thank you for helping us during this difficult time.


Date of Service
Eighth Client's Name

First Name*

Last Name*
Eighth Client's Date of Birth*
Eighth Client's Information
1. Are you experiencing any of the following symptoms?*
a. Severe difficulty breathing (deeply struggling for breath, can only speak in single words)
b. Severe chest pain
c. Difficult time waking up
d. Feeling confusion
e. Loss of consciousness
f. None

IF YOU ANSWERED CIRCLED ANY OF THE ABOVE, IMMEDIATELY CALL 911 OR GO DIRECTLY TO THE NEAREST EMERGENCY DEPARTMENT.

2. Are you experiencing any of the following symptoms?*
a. Difficulty breathing (struggling for breath, cannot hold breath for 10 seconds)
b. A fever
c. New cough
d. None
3. Are you experiencing any of the following symptoms that are not directly related to a known cause, i.e. arthritis, allergies, or recent injury?*
a. Muscle aches
b. Fatigue
c. Headache
d. Sore throat
e. Runny nose
f. None
4. Have you travelled outside of Canada in the last 14 days?*
Yes
No
5. In the last 30 days, have you been in contact with someone who is sick with respiratory symptoms (fever, cough, difficulty breathing) and who has recently travelled outside of Canada?*
Yes
No
6. In the last 30 days, have you been in contact with someone who has been diagnosed with COVID-19?*
Yes
No

We request that you please follow our infection control protocols during your visit with us. This will require hand hygiene, masks, etc.

Thank you for helping us during this difficult time.


Date of Service
Ninth Client's Name

First Name*

Last Name*
Ninth Client's Date of Birth*
Ninth Client's Information
1. Are you experiencing any of the following symptoms?*
a. Severe difficulty breathing (deeply struggling for breath, can only speak in single words)
b. Severe chest pain
c. Difficult time waking up
d. Feeling confusion
e. Loss of consciousness
f. None

IF YOU ANSWERED CIRCLED ANY OF THE ABOVE, IMMEDIATELY CALL 911 OR GO DIRECTLY TO THE NEAREST EMERGENCY DEPARTMENT.

2. Are you experiencing any of the following symptoms?*
a. Difficulty breathing (struggling for breath, cannot hold breath for 10 seconds)
b. A fever
c. New cough
d. None
3. Are you experiencing any of the following symptoms that are not directly related to a known cause, i.e. arthritis, allergies, or recent injury?*
a. Muscle aches
b. Fatigue
c. Headache
d. Sore throat
e. Runny nose
f. None
4. Have you travelled outside of Canada in the last 14 days?*
Yes
No
5. In the last 30 days, have you been in contact with someone who is sick with respiratory symptoms (fever, cough, difficulty breathing) and who has recently travelled outside of Canada?*
Yes
No
6. In the last 30 days, have you been in contact with someone who has been diagnosed with COVID-19?*
Yes
No

We request that you please follow our infection control protocols during your visit with us. This will require hand hygiene, masks, etc.

Thank you for helping us during this difficult time.


Date of Service
Tenth Client's Name

First Name*

Last Name*
Tenth Client's Date of Birth*
Tenth Client's Information
1. Are you experiencing any of the following symptoms?*
a. Severe difficulty breathing (deeply struggling for breath, can only speak in single words)
b. Severe chest pain
c. Difficult time waking up
d. Feeling confusion
e. Loss of consciousness
f. None

IF YOU ANSWERED CIRCLED ANY OF THE ABOVE, IMMEDIATELY CALL 911 OR GO DIRECTLY TO THE NEAREST EMERGENCY DEPARTMENT.

2. Are you experiencing any of the following symptoms?*
a. Difficulty breathing (struggling for breath, cannot hold breath for 10 seconds)
b. A fever
c. New cough
d. None
3. Are you experiencing any of the following symptoms that are not directly related to a known cause, i.e. arthritis, allergies, or recent injury?*
a. Muscle aches
b. Fatigue
c. Headache
d. Sore throat
e. Runny nose
f. None
4. Have you travelled outside of Canada in the last 14 days?*
Yes
No
5. In the last 30 days, have you been in contact with someone who is sick with respiratory symptoms (fever, cough, difficulty breathing) and who has recently travelled outside of Canada?*
Yes
No
6. In the last 30 days, have you been in contact with someone who has been diagnosed with COVID-19?*
Yes
No

We request that you please follow our infection control protocols during your visit with us. This will require hand hygiene, masks, etc.

Thank you for helping us during this difficult time.


Date of Service
Parent or Guardian's Email Address

Email*

Confirm Email*
info@mybeautiqueinc.com
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Information
1. Are you experiencing any of the following symptoms?*
a. Severe difficulty breathing (deeply struggling for breath, can only speak in single words)
b. Severe chest pain
c. Difficult time waking up
d. Feeling confusion
e. Loss of consciousness
f. None

IF YOU ANSWERED CIRCLED ANY OF THE ABOVE, IMMEDIATELY CALL 911 OR GO DIRECTLY TO THE NEAREST EMERGENCY DEPARTMENT.

2. Are you experiencing any of the following symptoms?*
a. Difficulty breathing (struggling for breath, cannot hold breath for 10 seconds)
b. A fever
c. New cough
d. None
3. Are you experiencing any of the following symptoms that are not directly related to a known cause, i.e. arthritis, allergies, or recent injury?*
a. Muscle aches
b. Fatigue
c. Headache
d. Sore throat
e. Runny nose
f. None
4. Have you travelled outside of Canada in the last 14 days?*
Yes
No
5. In the last 30 days, have you been in contact with someone who is sick with respiratory symptoms (fever, cough, difficulty breathing) and who has recently travelled outside of Canada?*
Yes
No
6. In the last 30 days, have you been in contact with someone who has been diagnosed with COVID-19?*
Yes
No

We request that you please follow our infection control protocols during your visit with us. This will require hand hygiene, masks, etc.

Thank you for helping us during this difficult time.


Date of Service
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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