Tiger Eye Salon COVID-19 Intake Form
We cannot service you at this time if: you answer ‘Yes’ to the below questions OR you have been off island in the last 14 days and haven’t completed a 14 day quarantine or tested negative for Covid 19.
Date
-
Month
-
Day
Year
Date
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 any of the above symptoms in the last 14 days?
*
Yes
No
3) Have you been out of the state or Maui County in the last 14 days?
*
Yes
No
4) If you answered ‘Yes’ to question #3, have you tested negative for Covid 19 or completed a 14 day quarantine?
Yes
No
Signature
*
Clear
Submit
Should be Empty:
Now create your own Jotform - It's free!
Create your own Jotform