COVID-19 Appointment Questionnaire
Date
*
-
Month
-
Day
Year
Date
Name
*
First Name
Last Name
What is your appointment time?
Hour Minutes
AM
PM
AM/PM Option
Who is your stylist?
*
Email
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
SELF DECLARATION
Are you exhibiting any of the following symptoms?
*
Fever
Dry Cough
Body Aches
Headache
Sore Throat
Runny Nose
Tiredness
Chills
Loss of Appetite
Loss of Sense of Smell or Taste
Nausea/Vomiting
Diarrhea
None of the Above
Have you travelled outside of Canada in the last 14 days?
*
Yes
No
If yes, which country(s)
Travel Dates? (Departure and Return)
Has anyone in your household been quarantined (self or directed) or identified as a COVID-19 confirmed or suspected case within the last 14 days?
*
Yes
No
To your knowledge, have you been exposed to anyone who has been quarantined (self or directed) or identified as a COVID-19 confirmed or suspected case within the last 14 days?
*
Yes
No
Are you currently waiting for a COVID-19 test result?
*
Yes
No
Signature
*
Submit
Should be Empty: