Appointment Health Form
Only fill this form in 24 hrs or less prior to your scheduled appointment
First & Last Name *
Do you have a fever? *
Do you have any shortness of breath? *
Do you have a dry cough? *
Do you have any flu-like symptoms? *
Have you experienced recent loss of taste or smell? *
Have you been in contact with any confirmed COVID-19 positive person? *
If you have been in contact with any confirmed COVID-19 positive person, have you been tested yourself?
Clear selection
Date tested:
MM
/
DD
/
YYYY
Have you tested positive for COVID-19 in the last 30 days?
Clear selection
Date of your positive result?
MM
/
DD
/
YYYY
Date of your negative result?
MM
/
DD
/
YYYY
Submit
Never submit passwords through Google Forms.
This form was created inside of Blu Salon. Report Abuse