Based on the Provincial and Public Health Agency of Canada (PHAC) guidelines, service providers are encouraged to screen all clients for signs of respiratory illness accompanied by fever.
All clients entering SUGAR THAT must be asked the following questions. SUGAR THAT will maintain this record for 14 days, beginning with the completion of this form, and this form will be made available upon request by the Public Health Department. By [checking this box/signing/], I pledge to provide only correct and truthful information when completing this screening.
I acknowledge the contagious nature of the Coronavirus/COVID-19 and that the Public Health Agency of Canada (PHAC) and many other public health authorities still recommend practicing social distancing.
I further acknowledge that SUGAR THAT has put preventative measures in place to reduce the spread of the Coronavirus/COVID-19.
I further acknowledge that SUGAR THAT cannot guarantee that I will not become infected with the Coronavirus/COVID-19. I understand that the risk of becoming exposed to and/or infected by the Coronavirus/COVID-19 may result from the actions, omissions, or negligence of myself and others, including, but not limited to staff of SUGAR THAT.
I voluntarily seek services provided by SUGAR THAT and I acknowledge that I am increasing my risk of exposure to the Coronavirus/COVID-19. I acknowledge that I must comply with all set procedures to reduce the spread during my appointment.
I attest that:
* I am not experiencing any symptoms of illness, such as cough, shortness of breath and/or difficulty breathing, fever, chills, repeated shaking with chills, muscle pain, headache, sore throat, or new loss of taste or smell.
* I have not traveled outside of Canada in the last 14 days.
* I do not believe I have been exposed to someone with a suspected and/or confirmed case of the Coronavirus/COVID-19.
* I have not been diagnosed with Coronavirus/COVID-19 and/or have been cleared as non-contagious by local public health authorities.
* I am following all recommended guidelines as closely as possible and I am limiting my exposure to the Coronavirus/COVID-19.
In addition, please be aware of the following protocols:
You will be required to sanitize hands immediately upon entry to SUGAR THAT
Masks or facial coverings are required to be in place prior to entry
One person per appointment unless accompanying a minor
Limit personal belongings