TMM Covid 19 Screening

1
Full Name* This field is required.
First Name
Last Name
2
Phone Number* This field is required.
Area Code
Phone Number
3
Email* This field is required.
example@example.com
Email Verified
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4
Check the conditions that apply to you or to any members of your household and/or persons you come in contact with:* This field is required.
Asthma
Cancer
Cardiac disease
Diabetes
Hypertension
Immunocompromized
None of the above
5
Are you currently taking any immunosuppressive medication (ex: prednisone(steroids), meds for lupus, meds for psoriasis, meds for hidradenitis, arthritis, etc)* This field is required.
Yes
No
6
Are you experiencing any of the following symptoms:* This field is required.
Cough
Fever (99.9° or higher)
Chest congestion
Labored breathing
Wheezing
Sore throat
Chills/shaking
Muscle/joint aches
Loss of taste
Loss of smell
None of the above
7
Have you experienced any of the following symptoms In the past 14 days:* This field is required.
Cough
Fever (99.9° or higher)
Chest congestion
Labored breathing
Wheezing
Sore throat
Chills/shaking
Muscle/joint aches
Loss of taste
Loss of smell
None of the above
8
Has anyone in your household experienced any of the following symptoms In the past 14 days:* This field is required.
Cough
Fever (99.9° or higher)
Chest congestion
Labored breathing
Wheezing
Sore throat
Chills/shaking
Muscle/joint aches
Loss of taste
Loss of smell
None of the above
9
Type a question* This field is required.Only one person will be allowed in the salon with the practitioner at a time. If guests arrive at the appointment with extra persons, they will be required to reschedule AND the late cancellation fee will be assessed. All guests must wear a mask to their appointment for all of the period that it is feasible. When guests arrive to scheduled appointment, they should remain in their car and call to let me know they have arrived. When I am ready to start the services, I will meet the guest at the door to let them in. Before entry, I will require the guest to have their temperature checked. If fever is present, the guest will be turned away and will not be able to reschedule for at least 14 days. Upon entering the salon space, guests must wash their hands. This also applies when the guest is leaving the salon space. If at any point during the appointment I feel or believe that the guest is displaying symptoms, or I discover that the guest has been around symptomatic people, I will stop the services immediately and ask the guest leave and reschedule at least 14 days later. If there is any time that a guest tests positive for Covid 19 after services are rendered (within 14 days of last appt), please notify me so that I can notify all that have been in the salon on the day that the services were rendered. Do you understand and agree to the terms I have explained to you set forth by The Arkansas Dept of Health?
YESNO
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