Covid-19 Consent Form

Risk Acknowledgment Form-Covid-19

* Indicates required field

Date *

Name *

First

Last

Address *

Phone Number *

I confirm that I am not presenting any of the following symptoms of COVID-19 listed below: • Temperature above 98.7 degrees • Shortness of breath • Loss of sense of taste or smell • Dry cough • Sore Throat * *

Yes No

I confirm to cancel all appointments at the studio if any symptoms develop, if I am required to self-isolate, or if I knowingly had close contact with someone who is confirmed or suspected of COVID-19. *

I confirmed

All personal information will be kept completely confidential by The Looking Glass & shall only be provided if requested by PEI health officials for contact tracing if required. *

I understand and agree for the above information to be access by Health officials if required for Covid-19 contact tracing only.

Submit

Please fill out before your Appointment Thank you!

Risk Acknowledgment Form-Covid-19

902-370-2700

Please fill out before your Appointment

Thank you!