Salon Visitor Questionnaire
As the outbreak of the coronavirus disease (COVID-19) continues to evolve and spread globally, T-Roots Beauty is closely monitoring the situation and the recommendations provided by the Centers for Disease Control and Prevention (CDC) and the NYS Department of Health.

In an effort to prevent the spread of COVID-19 and reduce the risk of exposure within the salon, we are requesting that visitors complete this short screening questionnaire on the DAY OF their scheduled appointment. Your participation is important to assist us in taking precautionary measures to protect you and others. Thank you.
Full Name *
Phone Number *
Appointment Date *
MM
/
DD
/
YYYY
Have you traveled internationally or outside of state in the last 14 days? *
1 point
Have you had any close contact in the last 14 days with someone with a diagnosis of COVID-19 or suspected to have COVID-19? *
1 point
Have you been in close contact with anyone who has traveled internationally within the last 14 days? *
1 point
Have you experienced any cold or flu-like symptoms in the past 24 hours or the last 14 days (including fever, chills, sweats, elevated temperature of 100F or greater, cough, sore throat, respiratory illness, difficulty breathing)? *
1 point
Current temperature: (I will provide you with this info at the time of your appointment) *
I certify that I will notify T-Roots Beauty immediately if any of my answers change within 14 days of taking this questionnaire. *
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