Medical History Form

Health Check Questionnaire

Your safety & that of all our families is a top priority. As part of health & safety protocols this questionnaire should be completed by all clients 24 - 48 hours BEFORE coming into the Salon for treatments. This is to ensure we protect everyone as much as we possibly can.
Name*

First NameLast Name
Phone Number*

Area CodePhone Number
Email
example@example.com
Appointment Date

DayMonthYear
Date
Covid 19 Vaccine*

I am fully vaccinated against covidI have had some covid vaccinesI haven't had any covid vaccines yet
It is not possible to have any treatments with 7 days of a booster vaccine or 14 days of a primary vaccine. If you have had a vaccine in the last month please give the date below.
Date of Covid vaccine if in last month

DayMonthYear
Date
Have you, anyone you live with or care for:*

experienced any symptoms of cold/flu or Covid in the last 7 daystested positive for Covid-19 in the last 7 daysfeel unwell in any wayNone of the above
If the answer to any of the above is yes or you're unsure please contact me on 07889 744348 as soon as possible as we may need to reshedule your appointment.
Signature

Clear
Date

DayMonthYear
Date
Please submit this form or email to novy@live.co.uk 24 hours before your appointment. Details collected will be held confidentially & in line with GDPR. We may use them to contact you if anyone reports symptoms & may also share this information with governing or medical authorities if required. If you have any questions please do ask!

Best wishes,

Joanne
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Health Check Questionnaire