COVID-19 Screening Questions. Must be completed before EVERY appointment, once via email or phone the day before your appointment and again the day of your appointment with your therapist. 

By attending my appointment...


I agree that I have not:

  • Tested positive for COVID-19

  • Knowingly been exposed to someone with COVID-19

  • Recently traveled to an area with a high infection rate

  • Been in an area where social distancing was not properly observed

  • Been to an establishment that has COVID-19 positive or pending cases in the past 14 days

  • Am awaiting the results of a COVID-19 test

  • Traveled outside of Canada in the past 14 days

  • Had close contact with a confirmed case of COVID-19 without wearing appropriate PPE

  • Been experiencing any of the below signs and symptoms


Do you have any of the following symptoms?

  • Fever

  • New onset of cough

  • Worsening chronic cough

  • Shortness of breath

  • Difficulty breathing

  • Sore throat

  • Difficulty swallowing

  • Decrease of loss of sense of taste or smell

  • Chills

  • Headaches

  • Unexplained fatigue/malaise/muscle aches (myalgias)

  • Nausea/vomiting, diarrhea, abdominal pain

  • Pink eye (conjunctivitis)

  • Runny nose or nasal congestion without other known cause


  • If you are 70 years of age or older, are you experiencing any of the following symptoms? • Delirium • Unexplained or increased number of falls • Acute functional decline • Worsening of chronic conditions

*COVID-19 Screening Results

If response to ALL of the screening questions is NO: COVID Screen Negative

If response to ANY of the screening questions is YES: COVID Screen Positive


If you screen Positive, you must reschedule your appointment to at least 14 days from now.


By attending my appointment I give consent to have my name and phone number added to the clinic contact tracing log should the Ministry of Health require it.

© 2013 by Mercury Massage Therapy. All rights reserved. Privacy Policy

Your Health is in Our Hands

670 Fortune Cres. Unit 6, Kingston, ON
(613) 900-1955
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