Covid Prescreening Form

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What is the first and last name of client being serviced?

Do you now have, or have you had over the past 14 days, any COVID-19 symptoms, including: - Cough - Shortness of breath - Sore throat - Nasal congestion/runny nose - Body aches - Loss of taste or smell - Diarrhea - Nausea - Vomiting - Fever or chills

Yes

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Have you had a diagnostic test for COVID 19 in the past 14 days?

Yes

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Have you had close contact with anyone who has tested positive for COVID-19 or has exhibited any of the above symptoms in the last 14 days:

Yes

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What is your temperature?

Do we have your consent to post pictures and videos of you on our social media platforms for promotional purposes?

Yes

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Please provide the date upon completion of this form:

YYYY

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