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Salon Pre Check -Form Fill
Section One
Q1
Name
First Name
Q2
Name
Last Name
Q3
Email
Q4
Phone Number
Area Code
Q5
Phone Number
Phone Number
Q6
I have been in contact with a person with a confirmed cased of COVID-19 in the past 14 days*
Yes
No
Q7
I have returned from overseas in the past 14 days*
Yes
No
Q8
I am currently in government mandated self-isolation*
Yes
No
Q9
I have had any of the following symptoms in the past 14 days: sore throat, a cough, a fever, difficulty breathing*
Yes
No
Q10
I have been in close contact/ live with someone who has returned from overseas in the past 14 days*
Yes
No
Q11
I have been in close contact or living with someone who is currently self-isolating?*
Yes
No
Q12
I am caring for someone who is unwell with a sore throat, a cough, fever or breathing difficulties*
Yes
No
Q13
I have been in close contact/ live with someone in the last 14 days who cares for someone with a confirmed or suspected COVID-19 case*
Yes
No
Q14
Signature
Q15
Date
Date
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