Mo Hair Express COVID-19 Client Service Pre-Screener

1

Name* This field is required.

First Name

Last Name

2

Email* This field is required.

example@example.com

3

Phone Number* This field is required.

Area Code

Phone Number

4

My Baseline pre-visit temperature must be below 99 degree Farenheit to receive a service. Today my temperature is :* This field is required.

5

I am aware that due to limited testing for the COVID-19, the virus has a long incubation period during which time carriers of the virus may be asymptomatic (no symptoms) and still be highly contagious. I also acknowledge that it is impossible to determine who has it .* This field is required.

Yes I Am Aware

6

I also acknowledge that I understand that anytime I am within close proximity (less than 6ft) of my service provider or any other person, I could have an elevated risk of contracting the virus should it be present.* This field is required.

Yes

7

I confirm that none of the following COVID-19 symptoms have been present within the last 2-14 days: Fever, Shortness of Breath, Loss of taste or smell, Dry Cough, Runny Nose, Sore Throat, Chills, Repeated Shaking with Chills, Muscle Pain or Head Ache* This field is required.

None of the above

Other

8

I affirm that I have not been exposed to anyone that has been diagnosed with COVID-19 within the past 14 days inside or outside of the country I reside in.* This field is required.

I Affirm

Other

9

I affirm that I have not traveled domestically (outside of my state) or internationally (outside of my country) within the past 14 days.* This field is required.

I Affirm

Other

10

Do you suffer from allergies? If yes, explain what are your allergy symptoms. If no, then put "Not Applicable or N/A" below.

11

I agree by providing my name below, I am in essence rendering my signature in acknowledgement of the completed statements on this form and that all information is accurate as of the date of this form.