Salon Cèmone
Purpose: Based on the US Center for Disease Control Guidelines and New Jersey Board of Cosmetology we are required to screen all clients for signs of respiratory illness accompanied by fever. You are required to fill out this form 24 hours before your scheduled appointment.Instructions: All clients entering Salon Cèmone will also be asked the following questions below at time of appointment. Salon Cèmone will maintain this record and have this form available upon request from the Public Health Department.
Name
*
First Name
Last Name
Today's Date
*
-
Month
-
Day
Year
Date
Please select YES or NO to the following questions:
1. Have you experienced any cold or flu-like symptoms in the last 14 days (to include fever, cough, sore throat, respiratory illness, difficulty breathing)?
*
YES
NO
2. Have you been in close contact with or cared for someone who has a confirmed COVID- 19 diagnosis?
*
YES
NO
3. Have you traveled out of state within the last 14 days?
*
YES
NO
4. Are you living with anyone who is sick or quarantined?
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YES
NO
Client Signature
*
Clear
Please verify that you are human
*
Submit
Should be Empty: