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Client Health Safety Survey
Please fill out this survey honestly and on the day of your appointment. Your service provider will review the survey and ensure she is able to perform your service.
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Enter full name here
*
Your answer
Who is your Service Provider?
*
Your answer
Please check the box if you are experiencing:
*
Fever (100.4 F or higher), or are feeling feverish?
Chills?
A new cough
Shortness of breath?
New muscle aches?
New headache?
New loss of smell or taste?
None of the Above?
Required
Are you currently waiting on COVID-19 test results?
*
Yes
No
Other:
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