Client Pre-Screening for COVID19
Please complete prior to salon visit.  By completing and submitting this form, you are knowinly and willingly consenting to having beauty and or barber care services performed during the COVID-19 Pandemic and you agree to adhere to all safety and sanitation protocols now required by the salon and or shops' service provider.
Sign in to Google to save your progress. Learn more
Name *
Email Address *
Phone Number *
Have you ran a temperature higher than 98.6 in the last 7 days? *
Have you traveled out of the state in the last 14 days? *
Have you been around anyone that has tested positive for COVID19? *
Are you aware that due to limited testing for the COVID-19, the virus has a long incubation period during which time carriers of the virus may be asymptomatic (no symptoms) and still be highly contagious. I also acknowledge that it is impossible to determine who has it . * *
Do you acknowledge that you understand that anytime you are within close proximity (less than 6ft) of the service provider or any other person, you could have an elevated risk of contracting the virus should it be present. * *
Have you had any of the following COVID-19 symptoms present within the last 2-14 days: Fever, Shortness of Breath, Loss of taste or smell, Dry Cough, Runny Nose, Sore Throat, Chills, Repeated Shaking with Chills, Muscle Pain or Head Ache * *
Have you had any of the following COVID-19 symptoms present within the last 2-14 days: Fever, Shortness of Breath, Loss of taste or smell, Dry Cough, Runny Nose, Sore Throat, Chills, Repeated Shaking with Chills, Muscle Pain or Head Ache * *
I agree by providing my name below, I am in essence rendering my signature in acknowledgement of the completed statements on this form and that all information is accurate as of the date of this form. * *
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy