COVID-19 Client Screening
PLEASE WAIT UNTIL THE DAY OF YOUR APPOINTMENT (AT LEAST ONE HOUR PRIOR) TO COMPLETE THIS FORM!

Please provide basic health-related information so we can take steps to ensure the safety of our artists, employees, and clients.

Our in-shop procedures and resources to help you understand the risks associated with novel coronavirus can be viewed at: https://www.moscowtattoocompany.com/covid-19
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Email *
I understand that any information shared may be utilized to contact me to inform of any risk of COVID-19 exposure. Contact and health information may be shared with health care authorities (i.e. Center for Disease Control, Health Department, etc.). *
Required
FULL NAME *
DATE OF BIRTH *
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DD
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YYYY
Which artist(s) will you be seeing (who should get a copy of your completed form)?
Have you felt "unwell" in the past 2 weeks? *
Have you been quarantined or cared for someone in quarantine at anytime in the past 30 days? *
Do you have any underlying health concerns (i.e. autoimmune disorder/problems, heart disease, asthma, COPD) that put you at higher risk for COVID-19 complications? *
Have you visited a hospital or emergency room in the past 3 months? *
Have you been in contact with anyone suspected of COVID-19 infection or who has displayed COVID-19 symptoms (i.e. shortness of breath, respiratory infection, cough, fever). *
Have you traveled out of the country in the past 6 months? *
Have you traveled out of Idaho in the past 6 months? *
Do you work in a nursing home ? *
Do you work with a COVID-19 at-risk population (i.e. elderly, immunocompromised, etc.)? *
Do you work in law enforcement or at a prison/jail? *
Are you a first responder? *
Are you an essential worker who has been in contact with people outside of your home? *
Where do you work? *
Have you been adhering to social distancing guidelines? *
Please explain any items you answered with "YES."
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