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?
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?
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?
In the last three weeks were you placed on quarantine by an employer or medical provider?
Are there any other symptoms not mentioned above that you have been experiencing?
Have you been tested for Covid-19 and awaiting results?
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.
Printed Client Name:_______________________________
Patient Temperature: __________ degrees F
Staff/Technician Signature: __________________________