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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*

Q7

I have returned from overseas in the past 14 days*

Q8

I am currently in government mandated self-isolation*

Q9

I have had any of the following symptoms in the past 14 days: sore throat, a cough, a fever, difficulty breathing*

Q10

I have been in close contact/ live with someone who has returned from overseas in the past 14 days*

Q11

I have been in close contact or living with someone who is currently self-isolating?*

Q12

I am caring for someone who is unwell with a sore throat, a cough, fever or breathing difficulties*

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*

Q14

Signature

Q15

Date

Date