COVID-19 Self Screening Questionnaire

COVID-19 Self Screening Questionnaire

You must answer these questions before we can book your appointment and before we arrive to groom your loved one. Please be honest. If you answer yes to any of these questions it does not always mean we won’t help. We love animals and will do whatever we can to help you and your furry family.

1) Have you had any of the following symptoms in the last 24 hours?*

	Yes	No
Cough
Shortness of breath of difficulty breathing

Have you received any Covid-19 vaccines? You are NOT required to answer this question.

	Yes	No	I Prefer Not to Say
Vaccine

OR at least TWO of the following symptoms in the last 24 hours:*

	Yes	No
Fever (usually 100.4 or higher)
Chills
Repeated shaking with chills
Muscle pain
Headache
Sore throat
New loss of taste or smell

2) In the last 14 days have you:*

	Yes	No
Been in contact with someone who was diagnosed with COVID-19?
Been in close contact with someone who had COVID-19 symptoms?
Traveled internationally or taken a cruise

If you answered “Yes” to any part of question two, You should consult your physician.

I certify to the best of my knowledge; this information is accurate.
Signature*

Clear
Name*

First NameLast Name
Phone Number

Area CodePhone Number
Email
example@example.com
Date*

MonthDayYear
Once you have submitted your form you are all done and will be redirected back to the website. Please note online booking has been disabled due to the high volume of requests we have been getting daily. We will contact you via text to discuss your appointment.
Do not fill this out if we haven’t spoken yet. It is only required once we have discussed your situation.

You are not required to answer if you have been vaccinated.
Should be Empty: