mend Massage: COVID-19 Patient Screening Form

Click on the calendar icon or within the box to select today's date.
Did you travel outside of Canada in the past 14 days?

Since you have travelled outside of Canada within the past 14 days, you are NOT cleared for an appointment today, November 28, 2020.

 

Did you travel outside of Ontario in the past 14 days?

Since you have travelled outside of Ontario within the past 14 days, you are NOT cleared for an appointment today, November 28, 2020.

 

Have you tested positive for COVID-19 or had close contact with a confirmed case of COVID-19 without wearing appropriate PPE?

Since you have tested positive for COVID-19 or had close contact with a confirmed case of COVID-19 without wearing appropriate PPE, you are NOT cleared for an appointment today, November 28, 2020.

 

Do you currently have or have you experienced any of the following symptoms in the last 14 days?
Please check all that apply.

Because you have one or more of the symptoms listed, you are NOT cleared for an appointment today, November 28, 2020.

 

 

Freedom of Information and Protection of Individual Privacy:

The information collected on this form is collected under the legal authority of the Ontario Colleges of Applied Arts and Technology Act, 2002, Ontario Regulation 34/03. The information is used for administrative and statistical purposes of the college and/or the ministries and agencies of the Government of Ontario and the Government of Canada. For further information, please contact the Registrar, Fanshawe College, P.O. Box 7005, London, Ontario, N5Y 5R6, telephone: 519-452-4277.