Ageless Perfection Skin Care Studio COVID-19 Screening RE-VISIT Form
This REQUIRED form will be kept as an individual client record for studio guest each time come in for their scheduled service/product pickup appointment. It is required to ensure that during the COVID-19 Pandemic, there are no symptomatic signs of the virus during the visit. You agree to adhere to all safety and sanitation protocols now required by the Ageless Perfection Skin Care Studio.
Email *
First Name *
Last Name *
Temperature at appointment (To be completed by RP) :
Do you have any of the following symptoms present today or in the last 14 days: Extremely Tired, Fever, Shortness of Breath, Loss of taste or smell, Dry Cough, Runny Nose, Sore Throat, Chills, Repeated Shaking with Chills, Diarrhea/Nausea, Muscle Aches/Pain, Headache, Pink Eye, Congestion, Pressure in Chest? IF YOU HAVE HAD ANY OF THESE SYMPTOMS, YOUR APPOINTMENT WILL NEED TO BE RESCHEDULED. *
I affirm that I have not traveled domestically (outside of my state) or internationally (outside of the United States) within the past 14 days. IF YOU TRAVELED AS DESCRIBED, YOUR APPOINTMENT WILL NEED TO BE RESCHEDULED. *
I affirm that I have not been in a large crowd (more than 5 people that do not live in the house with me) not wearing a mask and staying 6 ft apart. IF YOU HAVE BEEN IN A CROWD LARGER THAN 5 PEOPLE, YOUR APPOINTMENT WILL NEED TO BE RESCHEDULED. *
I am aware and understand that I am REQUIRED to wear a mask at all times, unless receiving a facial or facial treatment. If I arrive not wearing a mask, I will be given a mask to wear. If I refuse to wear mask, I will be instructed to leave. *
Have you been in contact with anyone that has been diagnosed with the COVID-19 virus in the past 14 days? IF YOU HAVE HAD THE VIRUS OR HAVE BEEN IN CONTACT WITH SOMEONE DIAGNOSED, YOUR APPOINTMENT WILL NEED TO BE RESCHEDULED. *
Signature (Type Below) *
Date *
MM
/
DD
/
YYYY
Time *
Time
:
A copy of your responses will be emailed to the address you provided.
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy