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Covid 19 Health Waiver -Form Fill

Q1

First Name

Client Name
Q2

Last Name

Client Name
Q3

Have you experienced symptoms, or been treated for the Coronavirus in the last 30 days?*
Q4

Have you been in contact with someone affected by the Coronavirus in the last 14 days?*
Q5

Have you traveled outside of the country in the last 14 days?*
Q6

Have you remembered to bring a face mask that loops behind your ears, and not your head?*
Q7

Do you understand your service can be denied if you show concerning signs and symptoms (cough, shortness of breath, fever above 100 degrees).*
Q8

Client Signature*