Jax-Zen COVID-19 Screening Questionnaire

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Name (First/Last) *

Phone number *

Have you had a fever in the last 24 hours of 100 degrees Fahrenheit or above? (If your answer is YES, please contact us to reschedule your appointment.) *

Yes

Do you now, or have you recently had, any respiratory or flu symptoms, sore throat, or shortness of breath? (If your answer is YES, please contact us to reschedule your appointment.) *

Yes

Do you now, or have you recently had, any chills. Muscle aches, new loss of taste or smell, or new rashes or lesions? (If your answer is YES, please contact us to reschedule your appointment.) *

Yes

Have you recently tested positive for an active, COVID-19 viral infection or received a positive result for a coronavirus antibody test? (If your answer is YES, please contact us to reschedule your appointment.) *

Yes

Have you been in contact with anyone in the last 14 days who has been diagnosed with COVID-19 or has coronavirus-type symptoms? (If your answer is YES, please contact us to reschedule your appointment.) *

Yes

Important! For your safety and ours, we are requiring all guests (regardless of vaccination status) to wear a face mask. Additionally, your temperature will be taken upon arrival. *

I acknowledge and agree to wear a mask and have my temperature taken.

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