Name *

First Name

Last Name

1. In the last 14 days, have you had or do you have a fever? (Average normal body temperature taken orally is about 37°C) *

NO

YES (If yes, please reschedule your appointment and contact your family doctor)

2. In the last 14 days, have you had or do you have a fever? (Average normal body temperature taken orally is about 37°C) *

New onset of cough

Worsening chronic cough

Sore throat

Shortness of breath (mild or moderate)

Difficulty breathing

New loss or decrease in sense of taste or smell

Runny nose

Sneezing (not allergy related)

Hoarse voice

Nasal congestion

Chills

Headache or muscle aches

Unexplained fatigue or malaise

Difficulty swallowing

Nausea/vomiting, diarrhea, abdominal pain

Confusion, losing consciousness or having a hard time waking up

Stuffy nose

Conjunctivitis (Pink Eye)

Skin rashes or discoloration of fingers or toes

None of the above

3. Have you travelled outside of Canada, or have had close contact with anyone who has travelled outside of Canada in the past 14 days? *

NO

YES (If yes, please reschedule your appointment)

4. Have you travelled outside of BC in the last 14 days? If yes, please note where? *

NO

YES

5. Have you had close contact with anyone with respiratory illness or a confirmed or probable/suspected case of COVID-19? *

NO

YES

6. If you answered Yes to question 4, did you wear the required and/or recommended PPE according to the type of duties you were performing (e.g., goggles, gloves, mask and gown or N95 with aerosol generating medical procedures) when you had close contact with a suspected or confirmed case of COVID-19? *

N/A as no close contact with anyone with respiratory illness or a confirmed or probable/suspected case of COVID-19 No (If no, please reschedule your appointment)

YES- If you have checked off signs or symptoms, you may need to reschedule your appointment. Please contact us as soon as possible. If you have answered "yes" to question 4 but "yes" to question 5, you may proceed with your appointment.

JANE OFF MAIN'S NEW PROTOCOLS *

Please arrive no more than 10 mins early for your appointment time. We will be limiting the number of people allowed in the reception area at a time. Alternatively, you could wait in your car or outside if the weather permits. Also, please arrive unaccompanied, unless you are a minor or require assistance. Please bring and wear a mask at all times while inside. If you forget to bring your own mask, a disposable one can be provided for you. It is important to avoid touching our faces during this time, particularly our eyes, mouth and nose, as coronavirus can be spread by touch. As such we suggest using a tissue, which we will provide, if an itch must be addressed, and we will do the same. Masks will also help with this for many. We have placed a number of bottles of hand sanitizer, so please feel free to use them. There is also a sink in the hallway where you can wash your hands upon arrival and before you leave. If you need to cancel your appointment due to illness, please give us a much notice as you possibly can! No-shows will still be subject to a late-cancellation fee. Please practice social distancing as much as possible in our hallway and common areas, and follow any taped markers on the floor, and take note of any displayed signs. We would prefer that payments be done through a credit card on file. If this is an issue for you please call us prior to your appointment to let us know. We ask that all intake forms and appointment scheduling be done online, and if you have any questions a phone call or email is preferred. Furthermore, please do not bring any food or personal drinks into the service location at this time, with the exception of water bottles with lids. If there are any policies or procedures you are uncertain of, or if there is any further step that would make you feel safer, please let us know! Upon your arrival, we will ask you a few quick questions to confirm the status of your health and any potential contact with COVID-19. Most importantly! If, in the 14 days prior to your appointment date, you have had, or are coming down with, a cold, flu or any symptoms of COVID-19, or have been exposed to someone with symptoms of COVID-19, or have traveled outside of Canada, please do not come in for your appointment. Rest at home and contact your family doctor as needed, or call 8-1-1.

I agree.

What you can expect from us: *

Here at Jane Off Main take the health and safety of our patients and ourselves very seriously. We will be taking extra time and care to regularly disinfect and clean all of our treatment areas and equipment, and the common areas including all counters, surfaces and door handles. As always, we will continue to follow all Coastal Health guidelines regarding the cleaning of linens, equipment, and of course hand hygiene with frequent hand washing. We will also be wearing masks while in the clinic common areas. Use of the mask for both esthetician and patient while in treatment rooms is expected. We will follow all protocols put in place by our various colleges, and will update our policies and procedures as necessary. We promise to be as vigilant with the status of our own health and exposure. We complete a daily self-assessment. We promise not come in to provides services should we develop any symptoms, or come into contact with COVID-19.

I agree.

Pre-Screening Upon Arrival at Jane Off Main

Upon your arrival at Jane Off Main, we will ask you a few quick questions to confirm the current status of your health and any potential contact with COVID-19. Please understand for the safety of ourselves and our extended families, as well as for the other patients of ours, if we feel that you do not meet the pre-screening criteria on physical presentation, we will cancel your appointment and suggest you contact your family doctor or call 8-1-1. We also recommend you complete the BC COVID-19 Symptom Self-Assessment tool prior to arrival. This can be found at https://bc.thrive.health/covid19/en

By checking this, I am declaring that I understand the necessity of screening prior to treatment, and will accept the therapist's decision if they do not feel that I meet the pre-screening criteria. I also acknowledge that I likewise have the choice to cancel my appointment should I feel that my therapist does not meet the pre-screening criteria, or should I feel unsafe to continue with treatment.

Consent to In-Person Service at Jane Off Main *

Due to the nature of service received at Jane Off Main, it is not possible to maintain physical distancing while in the treatment room. We have implemented pre-screening, physical distancing in the common areas, use of masks and tissues to avoid face touching, strict hand hygiene, and enhanced cleaning, along with other protocols, to help reduce the risk of transmission of COVID-19. However, we cannot reduce the risk to zero. Please understand that consenting to receive treatment in-person at Jane Off Main does put you at risk, and if you do not wish to take this risk please let us know so we can cancel your appointments.

By checking this, I am stating that I understand the risk of transmission and I consent to in-person treatment at Jane Off Main.

Declaration of Good Faith *

We here at Jane Off Main are doing our best to keep ourselves, our families and our patients safe!

By checking this I am declaring that I have read and understood the previous information. I am agreeing to comply with all policies and procedures implemented by Jane Off Main. And I declare myself safe and healthy to enter the clinic space. Furthermore, I acknowledge that should anything change with my state of health or should I come in contact with COVID-19, I will let you know and cancel my appointments.