COVID-19 Screening Questionnaire
Due to the coronavirus (COVID-19) this form must be filled out before entering and receiving your service at Exclusive Spa, Inc. We appreciate your patience and understanding.
First name *
Your answer
Last name *
Your answer
Email address *
Your answer
Phone number *
Your answer
Name of your service provider *
Your answer
Do you/they have a cough? *
Are you/they having shortness of breath or any other difficulties of breathing? *
Have you/they experienced recent loss of taste or smell? *
Any other flu-like symptoms, such as gastrointestinal upset headache or fatigue? *
Do you/they have a fever or have you/they felt hot or feverish recently within the last (14-21 days)? *
Are you/they over the age of 60 or are you living in an assisted living home? *
Have you traveled in the past (14-21 days) in any region affected by the COVID-19 or hot spots? *
I HEREBY UNDERSTAND THE FOLLOWING: *
Required
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