Avarté Covid-19 Pandemic Patient Questionnaire

Avarte strives to offer cosmetic tattooing services in the safest environment possible. We require our clients to be active participants in our efforts to stem the disease. In our communications, we ask that no client enter our building if they feel unwell or if they have had any exposure to anyone who is sick or feeling unwell.

Please answer each question and sign below.

Do you currently feel ill/unwell? Do you have any of these symptoms? Cough, sore throat, fever, shortness of breath, or fatigue?               Yes        No

Have you been around anyone who has been sick in the last three weeks or had contact with anyone with a lab confirmed Covid-19 or under investigation for Covid-19?

           Yes        No

Are you currently taking any cold or flu medication or a fever reducer such as Tylenol (acetaminophen) or Advil (ibuprofen)?           Yes        No

Are you experiencing a loss of taste or smell?

         Yes        No

Do you live or have you visited a community where the community-based spread was high or continues to be spreading at a high rate?

        Yes        No

In the last three weeks were you placed on quarantine by an employer or medical provider?

        Yes        No

Are there any other symptoms not mentioned above that you have been experiencing?

        Yes        No

Have you been tested for Covid-19 and awaiting results?

        Yes        No

I certify that the preceding history statements are true and correct. I am aware that it is my responsibility to inform the technician of my current medical or health conditions related to Covid-19 or other concerning medical issues.

Date:_____________________

Printed Client Name:_______________________________

Client Signature:__________________________________

Patient Temperature: __________ degrees F

Staff/Technician Signature: __________________________