Dahlia Beauty Pre-Appointment Covid-19 Health Screening Form
Please answer all questions prior to your appointment. Failure to provide honest answers or refusal to answer any part will result in cancellation of your appointment.
Name
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First Name
Last Name
Email
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example@example.com
Phone Number
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mobile phone number
Please indicate if any of the following apply to you
I am experiencing flu-like symptoms, such as fever, sore throat, cough, runny nose or shortness of breath etc
A close contact or member of my household is experiencing flu-like symptoms
I have returned from overseas travel in the last 28 days
A close contact or member of my household has returned from overseas travel in the last 28 days
I have been directed to self quarantine
I have been in contact with a suspected or confirmed case of covid-19
I am awaiting results of covid-19 testing
I am feeling unwell
Do you live in one of the restricted postcode areas: 3012, 3021, 3032, 3038, 3042, 3046, 3047, 3055, 3060, 3064, 3031, 3051?
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Yes
No
I understand giving false or misleading information is an offence and if so my appointment will be denied.
I am aware and agree to the following guidelines for my appointment (please tick to indicate you agree)
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I agree to not bring any guests, friends or family (including children) with me to my appointment. I understand not to enter the salon early for my appointment as I am aware there will not be a waiting area available. I agree to wash or sanitise my hands upon entry and after touching any items (either salon or personal). I understand my appointment will be denied if I present with any flu-like symptoms. I agree to keep a 1.5m distance from any other person outside the treatment room. If requested I agree to have my temperature taken and wear a disposable mask during my treatment. I agree to provide my correct contact details for tracing in the event of an outbreak. If my health status or situation relating to covid-19 changes after submitting this form I agree to notify Dahlia Beauty immediately to reschedule my appointment.
Signature
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Date
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Day
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Month
Year
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Please verify that you are human
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Submit
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