COVID-19 SCREENING FORM
Indigo Salon and Day Spa
Full Name
*
First Name
Last Name
Name
First Name
Last Name
Email
example@example.com
Phone Number
*
-
Area Code
Phone Number
COVID-19 RELATED QUESTIONS
Have you been vaccinated for COVID-19?
Yes
No
Have you or anyone in your household been tested for COVID-19?
*
Yes
No
Have you or anyone in your household had any of the following symptoms in the last 21 days: sore throat, cough, chills, body aches for unknown reasons, shortness of breath for unknown reasons, loss of smell, loss of taste, fever at or greater than 100 degrees Fahrenheit?
*
Yes
No
Have you or anyone in your household visited or received treatment in a hospital, nursing home, long-term care, or other health care facility in the past 30 days?
*
Yes
No
Have you or anyone in your household traveled in the U.S. in the past 21 days?
*
Yes
No
Have you or anyone in your household traveled on a cruise ship in the last 21 days?
*
Yes
No
Are you or anyone in your household a health care provider or emergency responder?
*
Yes
No
Have you or anyone in your household cared for an individual who is in quarantine or is a presumptive positive or has tested positive for COVID-19?
*
Yes
No
Do you have any reason to believe you or anyone in your household has been exposed to or acquired COVID-19?
*
Yes
No
To the best of your knowledge have you recently tested positive, or been in close proximity to any individual who recently tested positive for COVID-19?
*
Yes
No
If yes, please explain:
Have you colored your hair during the quarantine and if so what did you use?
*
If yes, please provide details
How long has it been since you have had your hair colored?
*
Ex. How many weeks, months, years
You are authorizing the staff at Indigo Salon and Day Spa to give you a fair and honest consultation. You understand that under the current circumstances the cost of your service may be higher than normal due to the recent pandemic. Additionally, you understand that you will incur a $2.50 pandemic fee during your visit(s).
*
I AGREE TO THE ABOVE TERMS
Date
*
-
Month
-
Day
Year
Date
Signature
*
Submit
Should be Empty: