This form is to be used as an individual client record for salon guest each time they visit the salon or shop for their scheduled service appointment. It is required to ensure that during the COVID-19 Pandemic, there are no symptomatic signs of the virus during this service visit. 6Questions
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Pre-Screen Covid-19
Name
First Name
Last Name
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Do you have any of the following symptoms present today: Fever, Shortness of Breath, Runny Nose, Loss of sense of taste or smell, Dry Cough, Sore Throat, Chills, Shaking with Chills, Muscle Pain, Head Ache*
*
Yes
No
Have you been in contact with anyone that has been diagnosed with the COVID-19 virus during the time between this service visit and my previous service visit? *
Yes
No
Email
example@example.com
Client's Temperature This Service Visit:*
*
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Have you left the country in the last 4 months?
Yes
No
Have you come in contact with someone who’s been diagnosed with Covid-19 in the past 14 days
Yes
No
Are you an health and hospital essential worker
Yes
No
Signature
Submit
Should be Empty: