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COVID-19 Questionnaire
For the safety of our staff and clients we are taking extra measures to keep the salon & spa a safe environment. Therefore, anyone coming into Dolce Vita Salon & Spa will be screened and part of our
screening process will include asking the following questions:
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* Indicates required question
Name:
*
Your answer
Phone Number:
*
Your answer
Email:
*
Your answer
Todays Date:
*
MM
/
DD
/
YYYY
Have you had a fever (100.4 Degrees F or higher) or felt feverish in the last 72 hours?
*
Yes
No
Have you been in close contact with a confirmed case of COVID-19?
*
Yes
No
Other:
Are you experiencing any respiratory symptoms including a runny nose, sore throat, cough, or shortness of breath?
*
Yes
No
Are you experiencing any new muscle aches or chills?
*
Yes
No
Have you experienced any new change in your sense of taste or smell?
*
Yes
No
Are You HIGH RISK?
*
Yes
No
Other:
Have you been in close contact with anyone who has been diagnosed or infected with Covid19 in the last 14 days??
*
Yes
No
Other:
Have you traveled in the past 14 days either Internationally (outside the U.S.) By cruise ship, or Domestically (within the U.S.) outside of NH, VT, or ME on public transportation (e.g., bus, train, plane, etc.).
*
Yes
No
Other:
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