COVID-19 screening The Lash Shrink LLC
12 HOUR SCREENING PRIOR TO APPOINTMENT
First and last name
Date of birth
Have you had any signs or symptoms of a fever in the past 24 hours such as chills, sweats, felt “feverish” or had a temperature of 100.4 F or greater?
Have you had any signs or symptoms of a fever in the past 24 hours such as
Shortness of breathe or chest tightness
Nasal congestion or runny nose
Loss of taste and/smell
None of the above
Have you experienced shortness of breath?
Have you been in contact with someone who has/ may have Covid-19 or who has been asked to self-quarantine?
Have you been tested for COVID-19?
Are you a healthcare provider?
Send me a copy of my responses.
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This form was created inside of Aruna Sundaram.