JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
COVID-19 screening The Lash Shrink LLC
12 HOUR SCREENING PRIOR TO APPOINTMENT
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Email
*
Your email
Name
*
First and last name
Your answer
Date of birth
*
Your answer
Phone number
*
Your answer
Have you had any signs or symptoms of a fever in the past 24 hours such as chills, sweats, felt “feverish” or had a temperature of 100.4 F or greater?
*
YES
NO
Required
Have you had any signs or symptoms of a fever in the past 24 hours such as
*
Cough
Shortness of breathe or chest tightness
Sore throat
Nasal congestion or runny nose
Body aches
Loss of taste and/smell
Diarrhea
Vomiting
Fever/chills/sweats
None of the above
Required
Have you experienced shortness of breath?
*
Yes
No
Other:
Have you been in contact with someone who has/ may have Covid-19 or who has been asked to self-quarantine?
*
Yes
No
Have you been tested for COVID-19?
*
Yes
No
Are you a healthcare provider?
*
Yes
No
Send me a copy of my responses.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
Privacy
Terms
This form was created inside of Aruna Sundaram.
Report Abuse
Forms
