Sapphire Hair Peterborough

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COVID-19 - Screening Questionnaire
You MUST complete this form before EVERY appointment.

Please enter your Full name. (First Name & Surname) *

What date was this form completed? *

YYYY

Date of your hair appointment *

YYYY

Have you or anyone in your household had Covid-19 in the last 14 days? *

Yes

Have you tested positive for Covid-19 in the last 14 days? *

Yes

Are you awaiting results from a Covid-19 test? If yes, please CANCEL your appointment until you know the result. *

I am awaiting results and will cancel my appointment

No I'm not awaiting test results

Have you had any of the following symptoms in the last 14 days? *

Fever

Shortness of breath

Continuous cough

Severe headache

Loss or change in sense of smell and/or taste

NONE OF THE ABOVE

Required

I understand that if I become ill with any symptoms, that I will cancel/rearrange my appointment. *

Yes I understand

If you or a family member becomes ill/have any symptoms after your appointment, I will get in touch with Sapphire Hair Peterborough to inform them. *

I will inform Sapphire Hair Peterborough

No I won't

I understand to keep you safe and to adhere to the government guidelines for 'Track and Trace' that this information will need to be kept for 1 month after your appointment. *

Yes I understand

I confirm and agree that the information provided is correct and accept it is my responsibility to inform Sapphire Hair Peterborough if there are any changes in circumstances. *

Yes I confirm and agree

Other:

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