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Nails And Beauty Consultation -Form Fill

Section One
Q1

Full Name*
Q2

Address*
Q3

Mobile contact*
Q4

Are you currently experiencing or have experienced any of the following symptoms in the last 14 days?*
Q5

Is anyone in your household experiencing any symptoms of COVID-19 (as above)? If you have answered 'yes', we advise that you should self-isolate for 14 days.*
Q6

Have you been in contact with anyone outside of your household who has been experiencing symptoms of COVID-19 in the last 7-14 days?*
Q7

Have you returned from travelling abroad in the last 14 days?*
Q8

If you have answered, yes, where and when?
Q9

Have you ever had a test for COVID-19*
Q10

If yes, what was the outcome and if you had to self-isolate, please provide dates of self-isolation.
Q11

Please note that we are obliged to notify NHS Track and Trace if circumstances require such. If we report any symptoms among staff or clients, or are contacted by NHS Track and Trace, we are legally obliged to provide them with your contact details and you may be contacted. Please confirm you have read and understood this statement.*
Q12

If you or anyone in your household develops symptoms associated with COVID-19 within 7 days of your treatment, you must immediately contact us.*
Q13

Agreement: (you must agree to all the statements below, if you do not, please kindly contact us to reschedule your appointment)*
Q14

I confirm that the information I have provided is truthful and to the best of my knowledge.*
Q15

If client is under 16 years old, please provide details of parent/guardian contact and parent to sign below.
Q16

Signature
Q17

Date of completion*

Month
Q18

Date of completion*

Day
Q19

Date of completion*

Year