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COVID-19 Screening Questionnaire
Due to the coronavirus (COVID-19) this form must be filled out before entering and receiving your service at Exclusive Spa, Inc. We appreciate your patience and understanding.
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First name
*
Your answer
Last name
*
Your answer
Email address
*
Your answer
Phone number
*
Your answer
Name of your service provider
*
Your answer
Do you/they have a cough?
*
Yes
No
Maybe
Are you/they having shortness of breath or any other difficulties of breathing?
*
Yes
No
Have you/they experienced recent loss of taste or smell?
*
Yes
No
Any other flu-like symptoms, such as gastrointestinal upset headache or fatigue?
*
yes
No
Do you/they have a fever or have you/they felt hot or feverish recently within the last (14-21 days)?
*
Yes
No
Are you/they over the age of 60 or are you living in an assisted living home?
*
Yes
No
Maybe
Have you traveled in the past (14-21 days) in any region affected by the COVID-19 or hot spots?
*
Yes
No
Maybe
I HEREBY UNDERSTAND THE FOLLOWING:
*
I will wear my mask at all times during my service.
I will keep 6 feet away from anyone in the salon.
I will come by myself to my appointment.
I understand I am here at my own risk.
If I am sick I will not come in.
I will let my temperature be checked when I come in.
Other:
Required
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