Surveypoint

Q1

Month

Date*

Q2

Day

Date*

Q3

Year

Date*

Q4

First Name

Name*

Q5

Last Name

Name*

Q6

Phone Number*

Q7

Prior to the start of my service, I confirm that:*

I do not have a pending COVID-19 test.

I have not been diagnosed with or cared for anyone with COVID-19 in the past 2 weeks.

I have not shown signs or been in close contact with anyone that is exhibiting these symptoms: COUGH, FEVER/CHILLS, SHORTNESS OF BREATH, DIFFICULTY BREATHING, SORE THROAT, LOSS OF TASTE OR SMELL, FATIGUE, HEADACHE, CONGESTION, OR RUNNY NOSE, NAUSEA OR VOMITING OR DIARRHEA

I have not traveled outside of my immediate daily routine for the past two weeks.

If I begin to show symptoms of COVID-19 within the next two weeks, I will contact my stylist.

I will follow all posted salon rules to keep myself, my stylist, and those around me safe.

Q8

Covid 19 Client Health Template -Form Fill

Month

Day

Year

First Name

Last Name

Phone Number*

Prior to the start of my service, I confirm that:*

Signature*