Mo Hair Express COVID-19 Client Revisit Form

1

Name* This field is required.

First Name

Last Name

2

Email* This field is required.

example@example.com

3

Client's Temperature This Service Visit:* This field is required.

4

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* This field is required.

YESNO

5

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? * This field is required.

YESNO

6

Signature* This field is required.