Tiger Eye Salon COVID-19 Intake Form
Thank you for taking the time to answer these questions
Date
-
Month
-
Day
Year
Name
First
Last
Phone Number
-
Area Code
Phone Number
1) Do you now, or have you had any of the following symptoms in the past 14 days: (select all that apply)
cough or sore throat
fever or you feel feverish
shortness of breath
loss of taste or smell
none of the above
2) Have you been around anyone with these symptoms in the last 14 days?
Yes
No
3) Have you been out of the state in the last 14 days?
Yes
No
Signature
Submit
Should be Empty: