Covid-19 (CoronaVirus) Questionnaire

To prevent the spread of COVID-19 and reduce the potential risk of exposure, we are conducting a simple screening questionnaire. Your participation is important to help us take precautionary measures to protect you and everyone in this building. Thank you for your time.

Date

Name*

First NameLast Name

Phone Number*

Area CodePhone Number

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

1. Have you returned from any of the countries listed on Coronavirus website within the last 30 days? https://www.cdc.gov/coronavirus/2019-ncov/travelers/after-travel-precautions.html*

YesNo

2. Have you been in close contact with anyone who has traveled within the last 30 days to one of the countries listed on the CDC website? https://www.cdc.gov/coronavirus/2019-ncov/travelers/after-travel-precautions.html*

YesNo

3. Have you had close contact with or cared for someone diagnosed with COVID-19 within the last 30 days*

YesNo

4. Have you experienced any cold or flu-like symptoms in the last 30 days (to include fever, cough, sore throat, respiratory illness, difficulty breathing)?*

YesNo

5.Have you recently been tested for Covid-19 and are still awaiting the results?*

YesNo

6.. By checking YES below, I do consent to having my temperature taken and understand that if my temperature is over 99* I will need to reschedule my appointment. I understand that if I check NO to consent that my appointment will be cancelled*

Yes, I consent to having my temperature takenNo, I do not consent and understand my appointment will be cancelled.

For everyone's safety, If you answered "yes” to any of the questions (except #6) you will be to contacted to reschedule your appointment. Thank you for your understanding.

COVID-19 is a highly contagious virus that spreads from person to person. In addition to long-held and explicit sanitation
measures this business has always adhered to, new preventative measures have been put in place to further reduce the
spread of this novel coronavirus. However, these best practices still offer no guarantee regarding your potential risk of being
infected.
Consent for Treatment
I understand that, because esthetics involves maintained touch and close physical proximity over an extended period of time, there may be
an elevated risk of disease transmission, including COVID-19. By signing this form, I acknowledge that I am aware of the risks involved from
receiving treatment at this time, I voluntarily agree to assume those risks, and I release and hold harmless the practitioner/business from any
claims related thereto. I give my consent to receive treatment from this practitioner.

Signature*