RE-LUXE HOME SERVICE MASSAGE"CLIENT SCREENING AND APPOINTMENT"
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OPERATING HOURS 24/7
NAME
ADDRESS
Contact Number
Age
Do you or your housemates have fever or have you felt hot or feverish recently (14-21 days)?
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Are you or your companion having shortness of breath or other difficulties breathing? 
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Do you or your housemate have a cough? *
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Do you or your housemate have any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue? 
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Are you or your housemate in contact with any confirmed COVID-19 positive patients?
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Are you or your housemates over 60 years of age? 
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Do you or your housemate have a heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders? 
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I hereby agree to the following below
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I hereby acknowledge that I have TRUTHFULLY and HONESTLY answered the questions and I have read and fully understood the guidelines and client consent form.
PREFFERED BOOKING  OF DATE
MM
/
DD
/
YYYY
Services to be availed
PREFFERED BOOKING OF TIME
Time
:
NOTES TO MASSEUSE OR OPERATOR
PREFFERED MASSEUSE
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