WELLNESS SCREENING
Please complete the following wellness screening prior to arrival. Our service providers will complete the same self screening with temperature checks prior to every shift.
Your First & Last Name
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Are you waiting on results of a COVID-19 test?
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NO
YES
When do you expect to receive your test results?
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Wellness Screening
Have you had a fever, cough or sore throat in the past 72 hours?
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NO
YES
Are you experiencing any other flu like symptoms such as a new or unusual headache (e.g., not related to caffeine, diet, or hunger and not related to a history of migraines clusters or tension, not typical) difficulty breathing or shortness of breath, muscle aches, chills or rigors, loss of taste or smell, or gastrointestinal concerns?
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NO
YES
Have you been in contact with anyone in the last 14 days who has been diagnosed with COVID-19 or has symptoms?
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NO
YES
Have you traveled outside of the state of Illinois in the past 14 days?
NO
YES
Where and when have you traveled?
Are you experiencing any other symptoms that may impact the health and wellness of service providers or guests at Inspired? If so, please explain.
Do you have any underlying medical issue or disability that will prevent you from wearing a face covering for the duration of your visit?
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NO
YES
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Special Accommodations
Face coverings will be required by all guests and service providers. Exceptions may be made when medically necessary by requesting reasonable accommodations in advance of your visit. Whenever possible, Inspired service providers will modify your service or appointment time to limit risk. If reasonable accommodations cannot be made, your service provider will advise you when we are able to reschedule your visit and will waive any appointment cancellation fees.
Please explain any accommodations you are requesting. Inspired partners will do their very best to meet your needs which may require a modified service or appointment time.
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Waiting on test results?
Any guest or service provider with pending test results for COVID-19 will not be allowed into our facility until those results are confirmed. Please submit this form and we will contact you to reschedule your visit.
Signature
I understand that the service I am requesting involves maintained touch and close physical proximity over an extended period of time. There may be an elevated risk of disease transmission, including COVID-19, and I agree to comply with the precautionary measures my service provider requires. Inspired Style Company and my service provider reserve the right to request additional screening or deny entry to any client for any reason. By signing this form, I acknowledge that I am aware of the risks involved in receiving services at this time. I voluntarily agree to assume those risks, and I release and hold harmless the service provider and Inspired Style Company from any claims related thereto.
I give my consent to electronically sign this form and attest that my answers are true to the best of my knowledge.
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Yes
Signature
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