Street Address Line 2
State / Province
Postal / Zip Code
Primary Phone Number
These questions must be answered honestly. Please answer YES or NO to each of the following questions:
Do you or anyone in your household has a fever or above normal temperature?
Have you experienced shortness of breath or had trouble breathing?
Do you have a dry cough?
Do you have a runny nose?
Have you recently lost or had a reduction in your sense of smell?
Do you have a sore throat?
Have you been in contact with someone who has tested positive for COVID-19?
Have you tested for COVID-19?
Have you been tested for COVID-19 and are awaiting results?
Have you or any of your household member traveled outside Australia by air or cruise ship in the past 14 days?
Have you or a household member traveled within Australia, by air, bus or train within the past 14 days?
Explain any YES answers in the box below:
*I understand that Strokes and Lashes and my lash/ brow artist cannot be held liable for any exposure to the virus or any other contagion caused by misinformation on this form or the health history provided by the client. Furthermore, I agree to not hold Strokes and Lashes and its associates if I do contract Covid-19 or any other contagion as I have decided to come here on my own free will. Signature: By typing your name in the box below, you acknowledge that your answers you provided are true and accurate to the best of your knowledge:
Should be Empty:
Now create your own JotForm - It's free!
Create your own JotForm