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Welcome to Brows by Laurie! I am looking forward to seeing you at your upcoming appointment. In preparation, I ask that you carefully read through and complete our COVID-19 infomed conent from and pre-screening questionnaire. Please do not hesitate to let me know if you have any additional questions or concerns.

COVID-19 Informed Consent Agreement

I am aware that exposure to COVID-19 can result in severe illness, intensive therapies, extended intubation and/or ventilator support, life-altering changes to my health, and even death. 



 

I understand in-person services increase the risk of my transmission of COVID-19 to my Service Provider and staff. This virus has a long incubation period, there may be as yet unknown aspects of its transmission, and I realize that I may be contagious, whether or not I have been tested or have symptoms.



 

To reduce the possibility of COVID-19 exposure or transmission at Brows by Laurie I accept that my Service Provider will implement infection-control procedures with which I must comply with during my service, for my own protection as well as that of my Service Provider. 


 
 

I understand my cooperation is mandatory, whether or not I personally feel such COVID-19 procedures and/or preventive measures are necessary.


 
 

I have read this COVID-19 Informed Consent Agreement and am authorized to consent on my behalf.

Client Signature:

April 10, 2021

First Participant's Name

First Name*

Middle Name

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information
In the last 14 days, have you travelled outside of Canada? If you are an essential worker who crosses the Canada-US border regularly for work, select "No."*
Yes
No
In the last 14 days, have you been identified as a "close contact" of someone who currently has COVID-19?*
Yes
No
In the last 14 days, have you received a COVID Alert exposure notification on your cell phone? If you already went for a test and got a negative result, select "No."*
Yes
No
Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)? **
Yes
No

Are you currently experiencing any of these symptoms? Choose any/all that are new, worsening, and not related to other known causes or conditions you already have.

Fever and/or chills - Temperature of 37.8 degrees Celsius/100 degrees Fahrenheit or higher*
Yes
No
Cough or barking cough (croup) - Continuous, more than usual, making a whistling noise when breathing (not related to asthma, post-infectious reactive airways, COPD, or other known causes or conditions you already have)*
Yes
No
Shortness of breath - Out of breath, unable to breathe deeply (not related to asthma or other known causes or conditions you already have)*
Yes
No
Difficulty swallowing - Painful swallowing (not related to other known causes or conditions you already have)*
Yes
No
Runny or stuffy/congested nose - Not related to seasonal allergies, being outside in cold weather, or other known causes or conditions you already have*
Yes
No
Pink eye - Conjunctivitis (not related to reoccurring styes or other known causes or conditions you already have)*
Yes
No
Headache - Unusual, long-lasting (not related to tension-type headaches, chronic migraines, or other known causes or conditions you already have)*
Yes
No
Extreme tiredness - Unusual, fatigue, lack of energy (not related to depression, insomnia, thyroid dysfunction, or other known causes or conditions you already have)*
Yes
No
Falling down often - For older people*
Yes
No
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

Last Name*
Second Participant's Date of Birth*
Second Participant's Information
In the last 14 days, have you travelled outside of Canada? If you are an essential worker who crosses the Canada-US border regularly for work, select "No."*
Yes
No
In the last 14 days, have you been identified as a "close contact" of someone who currently has COVID-19?*
Yes
No
In the last 14 days, have you received a COVID Alert exposure notification on your cell phone? If you already went for a test and got a negative result, select "No."*
Yes
No
Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)? **
Yes
No

Are you currently experiencing any of these symptoms? Choose any/all that are new, worsening, and not related to other known causes or conditions you already have.

Fever and/or chills - Temperature of 37.8 degrees Celsius/100 degrees Fahrenheit or higher*
Yes
No
Cough or barking cough (croup) - Continuous, more than usual, making a whistling noise when breathing (not related to asthma, post-infectious reactive airways, COPD, or other known causes or conditions you already have)*
Yes
No
Shortness of breath - Out of breath, unable to breathe deeply (not related to asthma or other known causes or conditions you already have)*
Yes
No
Difficulty swallowing - Painful swallowing (not related to other known causes or conditions you already have)*
Yes
No
Runny or stuffy/congested nose - Not related to seasonal allergies, being outside in cold weather, or other known causes or conditions you already have*
Yes
No
Pink eye - Conjunctivitis (not related to reoccurring styes or other known causes or conditions you already have)*
Yes
No
Headache - Unusual, long-lasting (not related to tension-type headaches, chronic migraines, or other known causes or conditions you already have)*
Yes
No
Extreme tiredness - Unusual, fatigue, lack of energy (not related to depression, insomnia, thyroid dysfunction, or other known causes or conditions you already have)*
Yes
No
Falling down often - For older people*
Yes
No
Third Participant's Name

First Name*

Middle Name

Last Name*
Third Participant's Date of Birth*
Third Participant's Information
In the last 14 days, have you travelled outside of Canada? If you are an essential worker who crosses the Canada-US border regularly for work, select "No."*
Yes
No
In the last 14 days, have you been identified as a "close contact" of someone who currently has COVID-19?*
Yes
No
In the last 14 days, have you received a COVID Alert exposure notification on your cell phone? If you already went for a test and got a negative result, select "No."*
Yes
No
Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)? **
Yes
No

Are you currently experiencing any of these symptoms? Choose any/all that are new, worsening, and not related to other known causes or conditions you already have.

Fever and/or chills - Temperature of 37.8 degrees Celsius/100 degrees Fahrenheit or higher*
Yes
No
Cough or barking cough (croup) - Continuous, more than usual, making a whistling noise when breathing (not related to asthma, post-infectious reactive airways, COPD, or other known causes or conditions you already have)*
Yes
No
Shortness of breath - Out of breath, unable to breathe deeply (not related to asthma or other known causes or conditions you already have)*
Yes
No
Difficulty swallowing - Painful swallowing (not related to other known causes or conditions you already have)*
Yes
No
Runny or stuffy/congested nose - Not related to seasonal allergies, being outside in cold weather, or other known causes or conditions you already have*
Yes
No
Pink eye - Conjunctivitis (not related to reoccurring styes or other known causes or conditions you already have)*
Yes
No
Headache - Unusual, long-lasting (not related to tension-type headaches, chronic migraines, or other known causes or conditions you already have)*
Yes
No
Extreme tiredness - Unusual, fatigue, lack of energy (not related to depression, insomnia, thyroid dysfunction, or other known causes or conditions you already have)*
Yes
No
Falling down often - For older people*
Yes
No
Fourth Participant's Name

First Name*

Middle Name

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information
In the last 14 days, have you travelled outside of Canada? If you are an essential worker who crosses the Canada-US border regularly for work, select "No."*
Yes
No
In the last 14 days, have you been identified as a "close contact" of someone who currently has COVID-19?*
Yes
No
In the last 14 days, have you received a COVID Alert exposure notification on your cell phone? If you already went for a test and got a negative result, select "No."*
Yes
No
Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)? **
Yes
No

Are you currently experiencing any of these symptoms? Choose any/all that are new, worsening, and not related to other known causes or conditions you already have.

Fever and/or chills - Temperature of 37.8 degrees Celsius/100 degrees Fahrenheit or higher*
Yes
No
Cough or barking cough (croup) - Continuous, more than usual, making a whistling noise when breathing (not related to asthma, post-infectious reactive airways, COPD, or other known causes or conditions you already have)*
Yes
No
Shortness of breath - Out of breath, unable to breathe deeply (not related to asthma or other known causes or conditions you already have)*
Yes
No
Difficulty swallowing - Painful swallowing (not related to other known causes or conditions you already have)*
Yes
No
Runny or stuffy/congested nose - Not related to seasonal allergies, being outside in cold weather, or other known causes or conditions you already have*
Yes
No
Pink eye - Conjunctivitis (not related to reoccurring styes or other known causes or conditions you already have)*
Yes
No
Headache - Unusual, long-lasting (not related to tension-type headaches, chronic migraines, or other known causes or conditions you already have)*
Yes
No
Extreme tiredness - Unusual, fatigue, lack of energy (not related to depression, insomnia, thyroid dysfunction, or other known causes or conditions you already have)*
Yes
No
Falling down often - For older people*
Yes
No
Fifth Participant's Name

First Name*

Middle Name

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information
In the last 14 days, have you travelled outside of Canada? If you are an essential worker who crosses the Canada-US border regularly for work, select "No."*
Yes
No
In the last 14 days, have you been identified as a "close contact" of someone who currently has COVID-19?*
Yes
No
In the last 14 days, have you received a COVID Alert exposure notification on your cell phone? If you already went for a test and got a negative result, select "No."*
Yes
No
Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)? **
Yes
No

Are you currently experiencing any of these symptoms? Choose any/all that are new, worsening, and not related to other known causes or conditions you already have.

Fever and/or chills - Temperature of 37.8 degrees Celsius/100 degrees Fahrenheit or higher*
Yes
No
Cough or barking cough (croup) - Continuous, more than usual, making a whistling noise when breathing (not related to asthma, post-infectious reactive airways, COPD, or other known causes or conditions you already have)*
Yes
No
Shortness of breath - Out of breath, unable to breathe deeply (not related to asthma or other known causes or conditions you already have)*
Yes
No
Difficulty swallowing - Painful swallowing (not related to other known causes or conditions you already have)*
Yes
No
Runny or stuffy/congested nose - Not related to seasonal allergies, being outside in cold weather, or other known causes or conditions you already have*
Yes
No
Pink eye - Conjunctivitis (not related to reoccurring styes or other known causes or conditions you already have)*
Yes
No
Headache - Unusual, long-lasting (not related to tension-type headaches, chronic migraines, or other known causes or conditions you already have)*
Yes
No
Extreme tiredness - Unusual, fatigue, lack of energy (not related to depression, insomnia, thyroid dysfunction, or other known causes or conditions you already have)*
Yes
No
Falling down often - For older people*
Yes
No
Sixth Participant's Name

First Name*

Middle Name

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information
In the last 14 days, have you travelled outside of Canada? If you are an essential worker who crosses the Canada-US border regularly for work, select "No."*
Yes
No
In the last 14 days, have you been identified as a "close contact" of someone who currently has COVID-19?*
Yes
No
In the last 14 days, have you received a COVID Alert exposure notification on your cell phone? If you already went for a test and got a negative result, select "No."*
Yes
No
Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)? **
Yes
No

Are you currently experiencing any of these symptoms? Choose any/all that are new, worsening, and not related to other known causes or conditions you already have.

Fever and/or chills - Temperature of 37.8 degrees Celsius/100 degrees Fahrenheit or higher*
Yes
No
Cough or barking cough (croup) - Continuous, more than usual, making a whistling noise when breathing (not related to asthma, post-infectious reactive airways, COPD, or other known causes or conditions you already have)*
Yes
No
Shortness of breath - Out of breath, unable to breathe deeply (not related to asthma or other known causes or conditions you already have)*
Yes
No
Difficulty swallowing - Painful swallowing (not related to other known causes or conditions you already have)*
Yes
No
Runny or stuffy/congested nose - Not related to seasonal allergies, being outside in cold weather, or other known causes or conditions you already have*
Yes
No
Pink eye - Conjunctivitis (not related to reoccurring styes or other known causes or conditions you already have)*
Yes
No
Headache - Unusual, long-lasting (not related to tension-type headaches, chronic migraines, or other known causes or conditions you already have)*
Yes
No
Extreme tiredness - Unusual, fatigue, lack of energy (not related to depression, insomnia, thyroid dysfunction, or other known causes or conditions you already have)*
Yes
No
Falling down often - For older people*
Yes
No
Seventh Participant's Name

First Name*

Middle Name

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information
In the last 14 days, have you travelled outside of Canada? If you are an essential worker who crosses the Canada-US border regularly for work, select "No."*
Yes
No
In the last 14 days, have you been identified as a "close contact" of someone who currently has COVID-19?*
Yes
No
In the last 14 days, have you received a COVID Alert exposure notification on your cell phone? If you already went for a test and got a negative result, select "No."*
Yes
No
Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)? **
Yes
No

Are you currently experiencing any of these symptoms? Choose any/all that are new, worsening, and not related to other known causes or conditions you already have.

Fever and/or chills - Temperature of 37.8 degrees Celsius/100 degrees Fahrenheit or higher*
Yes
No
Cough or barking cough (croup) - Continuous, more than usual, making a whistling noise when breathing (not related to asthma, post-infectious reactive airways, COPD, or other known causes or conditions you already have)*
Yes
No
Shortness of breath - Out of breath, unable to breathe deeply (not related to asthma or other known causes or conditions you already have)*
Yes
No
Difficulty swallowing - Painful swallowing (not related to other known causes or conditions you already have)*
Yes
No
Runny or stuffy/congested nose - Not related to seasonal allergies, being outside in cold weather, or other known causes or conditions you already have*
Yes
No
Pink eye - Conjunctivitis (not related to reoccurring styes or other known causes or conditions you already have)*
Yes
No
Headache - Unusual, long-lasting (not related to tension-type headaches, chronic migraines, or other known causes or conditions you already have)*
Yes
No
Extreme tiredness - Unusual, fatigue, lack of energy (not related to depression, insomnia, thyroid dysfunction, or other known causes or conditions you already have)*
Yes
No
Falling down often - For older people*
Yes
No
Eighth Participant's Name

First Name*

Middle Name

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information
In the last 14 days, have you travelled outside of Canada? If you are an essential worker who crosses the Canada-US border regularly for work, select "No."*
Yes
No
In the last 14 days, have you been identified as a "close contact" of someone who currently has COVID-19?*
Yes
No
In the last 14 days, have you received a COVID Alert exposure notification on your cell phone? If you already went for a test and got a negative result, select "No."*
Yes
No
Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)? **
Yes
No

Are you currently experiencing any of these symptoms? Choose any/all that are new, worsening, and not related to other known causes or conditions you already have.

Fever and/or chills - Temperature of 37.8 degrees Celsius/100 degrees Fahrenheit or higher*
Yes
No
Cough or barking cough (croup) - Continuous, more than usual, making a whistling noise when breathing (not related to asthma, post-infectious reactive airways, COPD, or other known causes or conditions you already have)*
Yes
No
Shortness of breath - Out of breath, unable to breathe deeply (not related to asthma or other known causes or conditions you already have)*
Yes
No
Difficulty swallowing - Painful swallowing (not related to other known causes or conditions you already have)*
Yes
No
Runny or stuffy/congested nose - Not related to seasonal allergies, being outside in cold weather, or other known causes or conditions you already have*
Yes
No
Pink eye - Conjunctivitis (not related to reoccurring styes or other known causes or conditions you already have)*
Yes
No
Headache - Unusual, long-lasting (not related to tension-type headaches, chronic migraines, or other known causes or conditions you already have)*
Yes
No
Extreme tiredness - Unusual, fatigue, lack of energy (not related to depression, insomnia, thyroid dysfunction, or other known causes or conditions you already have)*
Yes
No
Falling down often - For older people*
Yes
No
Ninth Participant's Name

First Name*

Middle Name

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information
In the last 14 days, have you travelled outside of Canada? If you are an essential worker who crosses the Canada-US border regularly for work, select "No."*
Yes
No
In the last 14 days, have you been identified as a "close contact" of someone who currently has COVID-19?*
Yes
No
In the last 14 days, have you received a COVID Alert exposure notification on your cell phone? If you already went for a test and got a negative result, select "No."*
Yes
No
Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)? **
Yes
No

Are you currently experiencing any of these symptoms? Choose any/all that are new, worsening, and not related to other known causes or conditions you already have.

Fever and/or chills - Temperature of 37.8 degrees Celsius/100 degrees Fahrenheit or higher*
Yes
No
Cough or barking cough (croup) - Continuous, more than usual, making a whistling noise when breathing (not related to asthma, post-infectious reactive airways, COPD, or other known causes or conditions you already have)*
Yes
No
Shortness of breath - Out of breath, unable to breathe deeply (not related to asthma or other known causes or conditions you already have)*
Yes
No
Difficulty swallowing - Painful swallowing (not related to other known causes or conditions you already have)*
Yes
No
Runny or stuffy/congested nose - Not related to seasonal allergies, being outside in cold weather, or other known causes or conditions you already have*
Yes
No
Pink eye - Conjunctivitis (not related to reoccurring styes or other known causes or conditions you already have)*
Yes
No
Headache - Unusual, long-lasting (not related to tension-type headaches, chronic migraines, or other known causes or conditions you already have)*
Yes
No
Extreme tiredness - Unusual, fatigue, lack of energy (not related to depression, insomnia, thyroid dysfunction, or other known causes or conditions you already have)*
Yes
No
Falling down often - For older people*
Yes
No
Tenth Participant's Name

First Name*

Middle Name

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information
In the last 14 days, have you travelled outside of Canada? If you are an essential worker who crosses the Canada-US border regularly for work, select "No."*
Yes
No
In the last 14 days, have you been identified as a "close contact" of someone who currently has COVID-19?*
Yes
No
In the last 14 days, have you received a COVID Alert exposure notification on your cell phone? If you already went for a test and got a negative result, select "No."*
Yes
No
Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)? **
Yes
No

Are you currently experiencing any of these symptoms? Choose any/all that are new, worsening, and not related to other known causes or conditions you already have.

Fever and/or chills - Temperature of 37.8 degrees Celsius/100 degrees Fahrenheit or higher*
Yes
No
Cough or barking cough (croup) - Continuous, more than usual, making a whistling noise when breathing (not related to asthma, post-infectious reactive airways, COPD, or other known causes or conditions you already have)*
Yes
No
Shortness of breath - Out of breath, unable to breathe deeply (not related to asthma or other known causes or conditions you already have)*
Yes
No
Difficulty swallowing - Painful swallowing (not related to other known causes or conditions you already have)*
Yes
No
Runny or stuffy/congested nose - Not related to seasonal allergies, being outside in cold weather, or other known causes or conditions you already have*
Yes
No
Pink eye - Conjunctivitis (not related to reoccurring styes or other known causes or conditions you already have)*
Yes
No
Headache - Unusual, long-lasting (not related to tension-type headaches, chronic migraines, or other known causes or conditions you already have)*
Yes
No
Extreme tiredness - Unusual, fatigue, lack of energy (not related to depression, insomnia, thyroid dysfunction, or other known causes or conditions you already have)*
Yes
No
Falling down often - For older people*
Yes
No
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
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*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information
In the last 14 days, have you travelled outside of Canada? If you are an essential worker who crosses the Canada-US border regularly for work, select "No."*
Yes
No
In the last 14 days, have you been identified as a "close contact" of someone who currently has COVID-19?*
Yes
No
In the last 14 days, have you received a COVID Alert exposure notification on your cell phone? If you already went for a test and got a negative result, select "No."*
Yes
No
Has a doctor, health care provider, or public health unit told you that you should currently be isolating (staying at home)? **
Yes
No

Are you currently experiencing any of these symptoms? Choose any/all that are new, worsening, and not related to other known causes or conditions you already have.

Fever and/or chills - Temperature of 37.8 degrees Celsius/100 degrees Fahrenheit or higher*
Yes
No
Cough or barking cough (croup) - Continuous, more than usual, making a whistling noise when breathing (not related to asthma, post-infectious reactive airways, COPD, or other known causes or conditions you already have)*
Yes
No
Shortness of breath - Out of breath, unable to breathe deeply (not related to asthma or other known causes or conditions you already have)*
Yes
No
Difficulty swallowing - Painful swallowing (not related to other known causes or conditions you already have)*
Yes
No
Runny or stuffy/congested nose - Not related to seasonal allergies, being outside in cold weather, or other known causes or conditions you already have*
Yes
No
Pink eye - Conjunctivitis (not related to reoccurring styes or other known causes or conditions you already have)*
Yes
No
Headache - Unusual, long-lasting (not related to tension-type headaches, chronic migraines, or other known causes or conditions you already have)*
Yes
No
Extreme tiredness - Unusual, fatigue, lack of energy (not related to depression, insomnia, thyroid dysfunction, or other known causes or conditions you already have)*
Yes
No
Falling down often - For older people*
Yes
No
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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